Inquisitive Detective

A fairy tale starts as ... Once upon a time, a little girl was born to an average American family in a small town in Pennsylvania. The little girl`s name was Cynthia. She lived in your typical "Leave It To Beaver" household. Her mother was a homemaker, who always had cookies and milk waiting for her daughter when she returned home from school each day. Cynthia was extremely active and energetic. She was a precocious child and an overachiever in school, just like her siblings. She always assumed

By adopting the role as a facilitator, hygienists can still fulfill the fairy tale dreamed long ago

Cynthia Chillock, RDH, BS

A fairy tale starts as ... Once upon a time, a little girl was born to an average American family in a small town in Pennsylvania. The little girl`s name was Cynthia. She lived in your typical "Leave It To Beaver" household. Her mother was a homemaker, who always had cookies and milk waiting for her daughter when she returned home from school each day. Cynthia was extremely active and energetic. She was a precocious child and an overachiever in school, just like her siblings. She always assumed that she would grow up and go to college one day, since she was what they called "college material."

In those days, the career choices for women were limited to teaching, nursing, and dental hygiene. Cynthia chose dental hygiene because her two sisters had already taken the other two fields. She wanted to be different. She went to dental hygiene school dreaming of what every other dental hygiene student dreamed about in those days. She would get her dental hygiene degree, meet Prince Charming, get married, work five years full-time, and begin her family of 2.5 children. She would then take a short break from her dental hygiene career. When her 2.5 children were in school, Cynthia would once again return to her career, but only part-time. In the late 1960s and early 1970s, the thought was that women could still earn a decent salary by working as a hygienist two days per week. After all, her income would only be a secondary income. Well, in this particular fairy tale, the little girl`s dream did come true. It just didn`t come true exactly as she had envisioned it.

If Cynthia had viewed a crystal ball back in 1965, when she made this career decision, would she have chosen dental hygiene? Aren`t there better financial opportunities in the business world of the 1990s? How about personal achievement, autonomy, benefits, or feeling like part of a team? How about physically leaning over patients for 30-plus years doing the same thing over and over and over again? Isn`t that hard on your back and neck? Isn`t that a little boring?

Many issues are involved in burnout besides money. One thought that occurred to me about the entire burnout issue is the ongoing battle of "RDH Shortage - Fact or Fiction? You be the Judge!" Many of the burnt-out hygienists I`ve known have valuable experience and skills which require years to master. Unfortunately, they got frustrated and bored in their little cubicles, or felt stagnant. They got out.

Welcome back, facilitator

Maybe we could lure some of these hygienists out of retirement and back into the profession by offering a chance at greater fulfillment. The enticement could be "facilitating."

Throughout this article, I would like to share some ideas about facilitating. It could change the way hygienists practice their profession. It takes a certain amount of training and practice to be a facilitator, and you definitely need an inquisitive personality. Sometimes I feel a bit like a detective. I have, however, discovered that these changes have allowed my fairy tale to come true. My career is both challenging and extremely rewarding.

I have been called a Pollyanna, and most of my friends will attest to that characteristic. But I believe job satisfaction can be related to our attitudes and our willingness to make changes. We must also take some of the risks and responsibilities for their outcome. I made some of these changes, I will admit, kicking and screaming all the way. At one point, I, too, obtained my real estate license and considered a career change.

The best way for me to combat my frustration and burnout has not been to get out - but to jump in deeper. I became more involved.

The concept of "becoming more involved" has meant different things to me at different times in my life. It has meant going back to school for more education. It has meant advanced instrumentation skills. It has meant being more active in my professional association. For the last seven years, it has meant becoming more involved in our practice and our patients` lives.

Depending on which catchy buzz words are popular, I have heard what I do called many different things - treatment coordinator, patient advocate, patient/doctor liaison, patient translator. In our office, we call it a facilitator. Call it just plain nosy if you want. I feel facilitating is listening to the patient and responding appropriately.

In our office, my job is to assist the patients by giving them all the information they may need in order to make choices regarding their dental health. This could involve:

- Answering questions.

- Discussing financial arrangements.

- Creating written information.

- Drawing pictures, or showing models, slides, or X-rays.

- Anything else necessary to give patients a clear understanding of their condition and options for their mouths.

The right kind of questions

Facilitating patients requires time and asking many open-ended questions. The knack of asking the right questions can require practice, but you don`t need a PhD in psychology to develop some listening skills. Most dental hygienists, I have found, not only undervalue these skills we use daily but, even worse, most of us don`t even recognize that we have them.

To get started on asking "nosy" questions, first test yourself. Count the number of "yes" and "no" responses from your patients in a day. The larger the number the more open-ended questions you should develop. In self-defense, I point out that many of our questions elicit one-syllable grunts because of time constraints.

One of the biggest obstacles hygienists run into is the scheduling problem. I hear repeatedly, "I don`t have enough time in my schedule." And the truth is, if you continue to do things exactly the same way with the same schedule, you probably don`t. But, if you are creative, you can make time. Some offices may require a consultant or facilitator working with the entire team to make creative changes.

Other times, it`s as simple as reorganizing your appointment routine to ask questions at the beginning instead of the end. With some patients I have seen regularly, I start by asking a good catch-all question at the beginning of the hygiene appointment: "What has been going on in your mouth since your last appointment?" If they have something to report, it may require a follow-up question, such as, "Will you describe your symptoms further?" Or, "Tell me more about that." Sometimes the best question is a simple, "How may I help you today?"

I recognize that it`s difficult to do everything in a one-hour appointment. By the time you get the patient seated, update the medical history, take the blood pressure, do the periodontal probing, do an oral cancer exam, check the home care, do the instrumentation, write in the patient`s chart, and worry about cleanup and setup for the next patient, who has time to actually ask the patient what they think and want for their mouth? Been there! Done that! Bought the T-shirt!

What I am proposing is that questions be asked first. What have you got to lose? Why treat someone who has not chosen your treatment? You will discover that some of your patients don`t care if they keep their teeth. I know that`s hard for anyone in the dental profession to hear, but wouldn`t it be better to know that upfront? I am quite sure I am not the only hygienist who has worked her fingers to the bone, trying to achieve dental health for some patients by more aggressive cleanings every three months, because they refuse to see the periodontist or have root planing. I would try to give them the service free, but in a different form, or so I thought. I certainly did not achieve health for them. The only things I achieved was frustration, sore hands, and a miserable dental experience for those patients.

A cookbook method to facilitating in the dental practice is unavailable. You have to find what works and is comfortable for you in your own practice. At first, everything seems uncomfortable, and it may take several trial-and-error efforts to find out what works.

Charting a course

I can tell you what works in our office. Although facilitating is an ongoing process, most of the one-on-one quality time for facilitating is done during the exam appointment for new patients. A map with directions to the office is sent to new patients. A letter, which explains the exam procedure, is also enclosed. I conduct a one-hour interview with the patient prior to the periodontal evaluation and exposing the full-mouth X-rays. During this interview, I try to get as much information as possible about the patient`s knowledge of their mouth, past experiences, and attitudes about their teeth and mouth.

Several questions I may ask are, "What condition is your mouth in? How much dental treatment have you had in the past? What were those experiences like for you? Which areas in your mouth do you experience food packing when you chew? Which areas are sensitive? Sensitive to what?" Their answers will elicit more questions, such as, "How would you feel about wearing a denture?" Or, "What do you do on a daily basis to clean your teeth at home?"

One of my favorite questions is, "How do you feel about the appearance of your teeth?" If they are not happy with their smile, I may then ask, "How would you like the appearance to be different?" After that answer, I inquire, "If we could do something to make that change for you, would you want it done?"

I also ask questions about their medical history and try to get some family medical and dental history. The family dental history will sometimes give you better insight into patients` attitudes.

I then leave the room and return with the dentist. Upon my return, the patient will many times have additional information to add. I let the patient know that I am going to share the information we discussed and, if they wish to add anything or if I heard anything incorrectly, they should jump in at anytime. It takes me only five to 10 minutes to relay the information to the dentist which took me an hour to extract from the patient. Talk about a time saver! The dentist then performs his examination.

While the dentist cites the information for the dental assistant to record in the chart, I am filling in what we call our user-friendly tooth chart, using simple terms and explanations. We give the patient this chart and keep a copy for ourselves. Most of the time, when patients leave, they have all the same information we have regarding their mouth, including existing conditions and a mutually prioritized treatment plan. (Occasionally, if that patient has additional occlusal problems, it may require further investigation with models.)

A helping hand where needed

The written information assists the patient in communicating with other family members who may be involved in making financial decisions. Most of our patients say that they have never been asked what they want for their mouth. Instead, they have been told what should be done, or they have been nagged to floss more.

The dictionary defines facilitation as the act of making easy or easier. I believe it requires real teamwork in the office to encourage more facilitation and make it easier for everyone involved.

Your schedule may look different each day as you change the way you practice by adding facilitating time. I currently practice four days a week - two days of clinical and two days of facilitating. My job is to help patients clarify their desires and make sure they are ready for the dentistry they receive.

Facilitating also means doing whatever is necessary to make the day go smoother, including helping the other team members. I assist the dentist in joint examinations, treatment plans, and consultations. By being a part of all three phases, I can take notes and help decipher both the answers and the questions, if necessary. It`s important to not talk over the patient`s head with technical terms. (You can actually see their eyes glaze over when you get too technical and they mentally "check out.")

My role during consultations is more as a patient advocate. My ability to translate options into simple terms has helped the patient understand and accept treatment.

On some days, my facilitating is geared more toward the team. This could mean taking over a lengthy explanation for the dentist or the other hygienist in order to keep them on schedule. It could mean that I do the periodontal probing on a patient if the other hygienist is running late. It could mean writing letters to insurance companies or follow-up phone calls to a patient`s physician. On some days, facilitation means bringing a sense of humor to the office. The point is that the purpose of facilitating is to help each patient receive quality treatment from a plan they have chosen, on time, and in a gentle, caring fashion by unstressed professionals.

A scary start, but never boring

Days don`t always go according to my planned agenda. I must be flexible enough to handle changes from minute to minute, which occasionally leaves me feeling a little scattered. However, I can tell you I am never bored.

The hardest part for me was fear of losing my job. What if I didn`t generate enough revenue to warrant my dental hygiene salary in my new non-traditional role? Will the dentist still pay me? How will I support myself? Fear of failure is not a surprise when we step out of that traditional role to make changes. Don`t be afraid to try. You can deal with fear. I found that I required some facilitation of my own through counseling to help me move beyond those fears.

I believe that hygienists can be the best facilitators in the office because they have the clinical, educational, and behavioral skills to answer the patients` questions and explain procedures. The most important aspect of facilitating is responding appropriately, and their background prepares them to handle any situation that may arise.

The dentist, meanwhile, gains more time and freedom for more productive procedures during the working hours. Facilitating also assists the patients by helping them to clarify long-term goals for their mouth, usually for the first time in their lives. Helping the patients make a conscious decision about whether or not they really want to keep their teeth is an integral part missing in most dental practices.

Patients seem to trust the hygienist, and they do not perceive a conflict of interest because the hygienist doesn`t own the practice. Patients know the educational background of the hygienist, or soon will as you do more facilitating. They can be more open with the hygienist because there is still that perceived aura surrounding many doctors. Patients may not want to "waste the doctor`s time" or appear foolish by asking a "stupid question."

The patients sometimes may not feel they have enough information to know what questions to ask. When I read doubt in a patient`s eyes, I will pause to ask for a clarification, such as, "What part of my explanation seems confusing?" By my being available for facilitating, the patients know that we always have time to answer their questions.

Your knowledge, skills, and experience as a facilitator can result in a greater financial impact on the dental practice. Presenting, listening, and clarifying for the patients has increased the quality and quantity of the treatment in our office. Patients know we really care and are truly listening.

That is the key. Patients want to be heard, especially from those of us in a service-oriented profession. When they choose their own treatment, they will fully commit to the project. We have found that there has been an increase in the percentage of treatment acceptance by our patients. The partnership with patients has translated into fewer broken appointments and last-minute cancellations. They value the services we provide and happily pay the bill.

The wait for the dentist to check the patient after the hygiene appointment is completed is one of the most frustrating aspects of dental hygiene. If you think you`re frustrated, put yourselves in the dentist`s shoes. Imagine how they feel being interrupted eight to 10 times a day to check each hygiene patient. Switching mental gears several times a day can be exhausting, not to mention what a pain it is to change masks and gloves each time.

A separate exam appointment

But an exam appointment scheduled separately will allow enough time for patients to receive the undivided attention from their dentist and get all their questions answered.

I can hear the collective groan from all of you as I write this: "But it`s never been done that way! The patients will never go for it, and they sure won`t pay extra for a separate appointment. Anyway, the dentists won`t allow it."

Surprise. They do, they do, and they do. Our patients expect us to be practicing research-driven dental hygiene. They automatically assume we keep up with the current information and tell them about it. The patients neither expect nor want any of their health care professionals to treat them the way they were treated 20 years ago.

Our problem is making changes and deciding how to present those changes to our patients. I can give you one idea by telling you how I present this change to my patients. I tell patients that when "they have their teeth cleaned, I am seeing them at their worst, when the bacteria level is the highest. There is inflammation present whenever there is bleeding. My cleaning their teeth will allow the tissues to heal, creating more shrinkage at the gum line. This shrinkage enables the dentist to see better and do a more thorough evaluation. The best time for this examination is seven to 21 days after the teeth are cleaned."

When the patient is new to our practice, we handle this differently. At the initial exam, the dentist tells the patient, "You will find that we do things differently here. I will not be coming into the hygiene room to check your teeth after they are cleaned. I don`t feel I can be as thorough with the quick look-over-the-hygienist`s-shoulder exam. We will schedule you for an exam with me once a year at a separate appointment. If the hygienist sees any new areas of concern during your hygiene visits, she will call them to my attention, and I will check them that day. This way, I feel I can focus better, provide a better service for you, and be sure I`m not missing anything."

In our office, we will sometimes schedule a half-hour to 45-minute intraoral camera appointment prior to that exam appointment. The camera enables patients to see things they never could have seen with the naked eye and gives them time to begin formulating questions for the dentist during the exam. Nowadays, many people want cosmetic dentistry, but the quick exam after the hygiene appointment does not allow enough time for the patient, the dentist, or the hygienist to find out what the patient really wants.

So don`t be afraid to make time for more facilitating. You already do it all day long anyway. Just try a few changes. Next week, ask a new patient to your practice: "How do you feel about the appearance of your teeth?" Then listen.

Some patients have felt self-conscious about their smiles for years, but no one ever suggested cosmetic changes so they assumed nothing could be done. They get excited about the possibility of improving their smile. Isn`t our patients` healthy mouths and proud smiles what it`s all about?

Cynthia Chillock, RDH, practices in Tucson, Ariz. She is past president of the Arizona State Dental Hygienists` Association and co-owner of Perio-Data™ Co. She lectures nationally and is a office consultant and clinical tutor.

Open-ended questions

- "What do you do on a daily basis to clean your teeth at home?"

- "Which areas of your mouth are packing food when you chew?"

- "Which teeth are sensitive?"

- "Sensitive to what?" Or, "How often?"

- "How do you feel about the appearance of your teeth?"

- "How would you like the appearance to be different?"

- "How comfortable do your teeth feel when you chew?"

- "Will you describe your symptoms further?"

- "What part of my explanation seems confusing?"

- "What has been going on in your mouth since your last appointment?"

- "How may I help you?"

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