by Anne Nugent Guignon, RDH, MPH
If you grew up in the 1950s your family probably owned a new invention called the television. Programming was pretty tame in those days. You might even remember the series called Father Knows Best. Each week my family would crowd around our little television to watch the latest episode about the everyday adventures of the Andersons, an all-American family, who lived in Springfield, USA. Robert Young and Jane Wyatt played the parents of three kids ranging in age from 9 to 17.
The show mirrored post-World War II American culture. While the family members had input, the father was the leader and always made the final decision. This type of family culture may seem a bit prehistoric to many of you but this is the way things were "back then." Since most of us directly mirror our upbringing, it is not surprising that many of us thought our dentist/employer would provide everything we needed to take excellent care of patients. I call this the dental hygiene's Father Knows Best-era. For example, most hygienists who graduated more than a decade ago never thought of purchasing our their equipment. It just never would have occurred to us.
While many of us would not have considered taking ownership of our careers to this level, there were also very few product selections available. Dental hygiene practice remained fairly static with respect to equipment. For decades, most hand scalers were very similar. Twenty years ago only a few brave souls used power scalers regularly; most dental professionals did not routinely wear gloves; and other than saliva ejectors and gauze, most products were not disposable.
Some cultural norms are hard to change, but the culture in dental hygiene is beginning to take on a new dimension. While dental hygiene students have purchased their own hand instruments for years, things are changing in the halls of academia. A growing number of schools are encouraging or even requiring students to have their own magnification loupes. Today most students are expected to purchase their own ultrasonic scaling inserts, and a few remarkable programs are making it mandatory for students to purchase their own ultrasonic scaler upon entering the hallowed halls. What was unthinkable 10 years ago will be accepted practice in the future.
In addition to the mindset changes in the educational process, advances in science and technology have exploded during the past 15 years, resulting in a plethora of phenomenal products and incredible equipment. In addition, new periodontal instrumentation techniques are allowing us to achieve levels of clinical accuracy that we never dreamed would be possible. Today, we have so many choices it is hard to imagine going backward. But most people hate change, and dental professionals are no exception.
Hygienists face a unique situation. Those who are willing to consider purchasing their own equipment are often met with a blank stare from our dentist/employers. Hygienists who ask the doctor to provide something new often receive the same negative response. Perhaps this very common situation stems from the fact that most doctors do not use the equipment we use every day and therefore feel justified in adopting a "well it still works, doesn't it?" mentality.
This kind of response harkens back to the Father Knows Best era. From the doctor's point of view, some feel that every time they hire a new hygienist they get pressured into revamping the entire hygiene department. While this can be an exaggeration, how would you feel if you were in their shoes, and every new employee wanted all new equipment? There are closets filled with unused equipment all over the country. This does not endear us to our employers.
Another explanation we hear is that other parts of the practice have a greater need than the dental hygiene department. Some hygienists never see the economic trickle-down theory applied to their own treatment room. Money comes in the door but never makes it down the hall to the hygiene room. These clinicians work in dental hygiene closets with worn-out, substandard equipment and are expected to produce miracles under these conditions. Worse yet, they are made to feel guilty for asking for new instruments when their old ones should have hit the trash can months or even years before.
Freedom to choose
What happens when a hygienist finds the equipment she has been given to work with is in poor repair? What if it is vastly different from a technology that would allow her to practice with a high level of proficiency? What about the hygienist who finds it impossible to practice with someone else's idea of "great equipment" or is expected to practice with a hand-me-down from some previous century of dental hygiene? These are even more reasons why hygienists want the freedom to choose the equipment they use all day long.
Hygienists who purchase items such as customized magnification loupes are the perfect example of focusing attention on the long-term health of their career. Certainly, hygienists practicing with technology they understand and are comfortable with feel much less physical and mental stress during the workday. Less stress will most likely translate into a happier working environment where the focus can be on patient care, not on how to fiddle with a knob to make a worn-out piece of equipment work without harming the patient.
Even though there is a trend toward hygienists owning their own equipment, it is not the professional norm at this point. Be prepared for a variety of reactions. How are you going to feel when you are confronted with fear, disbelief, anger, annoyance, disdain and ridicule? Understand that you are setting yourself apart. Change can be scary, especially to those that may not understand why you are choosing to practice this way.
Your employer may perceive that you think you are superior to other hygienists or critical of their standards or equipment. How will your doctor respond if you start wearing loupes before he does? He could be concerned that you are getting "too independent" and will leave at the drop of the hat. Some doctors get concerned that they will have to purchase new equipment for other employees.
A secure doctor will applaud your initiative and respect you even more for making an investment in your career. Smart doctors realize the wonderful benefits to their practice when you are comfortable in how you work. Most doctors develop an entirely different relationship with a hygienist they have seen go the extra mile. While it is not true across the board, hygienists who go to the next level frequently receive a higher level of compensation as well as much less resistance to upgrading or replacing dental hygiene equipment in the future.
There can be a flip side of your doctor's admiration for your entrepreneurial enthusiasm. Some quickly get very, very used to you purchasing your own equipment. When push comes to shove, your attempt to control your own environment may make them think that you should provide every new piece of equipment from now on. If you are comfortable with that, OK. If you are not, then consider an alternative strategy that we'll discuss in a few minutes.
Your fellow hygienists might think you have gone off the deep end. Jealousy might be their initial emotional response. They might be feeling stupid or inadequate if they don't try to keep up with you. Are they secretly worried that the doctor might treat you differently or that you might get more attention?
What about the patients? Can they get used to the changes? What if they are resistant to your new ultrasonic scaler or do not understand why you are wearing loupes? Are you prepared to cope with their questions and concerns?
Education goes a long way to dispelling co-worker and patient fears. Try letting them know that you are worried about career longevity and repetitive stress injuries. Dispel any thoughts that you are trying to be superior. Show your hygiene friends what a difference magnification, illumination, or an ergonomic chair can make. If you handle it with tact, they'll respect your decisions and their fears will evaporate.
In some very rare circumstances, shading the truth may be a way of deflecting someone who treats your decisions with disdain rather than respect. My advice is, "Don't even go there!" Let them own their negativity and don't let them put you in a defensive position. Make them feel good, even if you have to massage your responses a bit.
Q: Why would you buy a chair? Aren't ours good enough for you?
A: I'm starting to have problems and my back, and this chair is really helping. Thanks for being concerned.
Q: Well, now that you have gotten yourself a fancy new scaler, just what are you going to want next?
A: It is amazing how much this new scaler has helped me practice so much better and more comfortably. Now I'm giving some serious thought about what other things will help me practice longer. Doesn't that sound like a great idea?
Support at home
There are hygienists whose partners do not believe or understand how hard we practice. They receive little or no support from their life mates with regards to education or equipment when they try to improve their professional careers.
It is tragic to hear about hygienists who desperately need something like a pair of magnification loupes or a better slow-speed handpiece, yet they feel that there is not enough money in the personal budget to support their health needs despite the fact that their mate just got another weekend toy.
While I would encourage every one of you to think about purchasing your own equipment there are a number of hygienists who work with dentists who fully support new technology and are willing to make the investment for their hygienist. If this is your situation, great — but there may be some very serious pitfalls just around the corner.
For example, what if your significant other (oh, yes this is a long way from the Father Knows Best lingo) is unexpectedly relocated to a town 1,000 miles away from your current practice? What if your Midwestern small town general practice is not challenging enough, and you have decided to move to a large cosmopolitan city half way across the country? What now? Who owns the equipment? Is it yours (the doctor's), mine, or ours? Should you repay the doctor for any equipment that is custom-fitted? What if you are the only one in the practice that ever uses a particular scaler? What if the instrument in question needs specific hands-on training? Now you have a whole new set of challenges to deal with.
The situation becomes even stickier if you and the doctor shared the cost of the product. What if you have only worked in the practice for nine months? What if you have been there for 19 years? Does it make a difference if you are a full-time or a part-time employee?
How would you handle this complicated situation? If you only work in a practice on Mondays and Wednesdays, do you take your equipment home with you at the end of every day? What happens if someone else uses it? Did they ask if they could? If the equipment has special settings like an ergonomic chair or flip-up magnification, will you feel like Goldie Locks when you find that your loupes or chair don't fit you and you have to spend time redoing all of the settings?
How do you want to address the situation if some one else uses your equipment, and it breaks under their watch? Are you willing to let them take a free ride at your expense? Tough questions yield messy answers ... unless you've got it in writing.
If we are savvy enough to own our own equipment then we need to look at our investment as a business adventure. If you don't have a written agreement with your employer, then you are setting the stage for a potentially serious misunderstanding. Rather than risk a blow-out, consider including this information in your agreement:
• Who gets to use the equipment?
• Who pays for disposables or consumables?
• Who pays for repairs?
• Who owns the equipment if you leave the practice?
• Will you have to buy it back from them when you leave?
• What if it is custom equipment and you leave?
• Are you entitled to a higher compensation if you use your own equipment?
• What if your equipment allows you to perform specialized treatment — will you be compensated at a rate that reflects a fair return to both you and the dentist?
• What happens if there is a power surge or a flood and your equipment gets damaged?
• If you co-own equipment, will it ever be yours free and clear, and at what point?
• Will you lease the equipment back to the doctor?
• Can you leave the equipment in the office on your day off?
• If it gets damaged when some one else is using it, who pays for the repairs?
• Who owns the equipment if the doctor becomes disabled, dies or sells the practice?
• What if you agree to accept equipment in lieu of a raise — is it yours?
Undoubtedly there are many other questions that can and will arise. Equipment ownership is new territory for many hygienists. Time has a funny way of erasing people's memories but a written agreement brings both parties back to the original table.
On a more positive note, there are some additional things that you need to consider.
If you purchase the equipment then you are entitled to a tax write-off. You can also write off the cost of any training, repairs and supplies. The IRS will require you to produce all records if there is ever a question so keep everything. If you pay for half of the equipment who takes the write off? Your tax professional should guide you about these matters but remember to save all receipts and document everything.
If you've made it this far then perhaps you'd like to know how your hygiene colleagues have handled these issues. The sidebars on page 73 tell the stories of four who have charted their own course. Each has a different take but there is a common thread to these stories. Everyone is winning: hygienists, doctors, and patients.
Having your own equipment is a way to make a decision and shows ownership in your professional career. It demonstrates that you are taking an active interest in how you practice. If we consider ourselves professionals then purchasing your own equipment is one way we can move toward a new level of professional maturity.
When Cappy did a working interview she brought her own ergonomic chair — the chair she had purchased to alleviate horrible back problems. The doctor was surprised but was impressed with her clinical skills and her professionalism. Cappy had found a practice that appreciated her! When she mentioned that she was going to purchase magnification loupes at the next dental meeting, her doctor got interested and purchased loupes for both of them. A fiber optic headlight was the next item on Cappy's wish list. Her husband encouraged her to make this purchase. In addition to purchasing equipment, Cappy's dentist understands what they have both invested and has been very willing to provide financial support for a number of CE programs, including RDH Under One Roof.
Diane is hardly a traditional thinker. When the periodontal endoscope came out, she knew it was the equipment she had always dreamed about. Even though her doctor supported the idea and was willing to make the purchase, the practice really needed new chairs and units, and he was worried about return on investment. Diane did not want hold the rest of the team back from their desire for new equipment and realized the Dental View 2 would pay for itself in good time, so she figured out a way to make the investment herself and got all of the necessary training.
When Diane uses the endoscope she gets 60 percent of the fee. She also has trained the other hygienist in the practice, and her agreement states that if the other hygienist uses it, Diane gets 50 percent of the fee, whether she is present or not. Endoscopic fees are considerably higher than routine hygiene fees. Diane pays for the bulbs for this device and the disposable sheaths are billed to the patients. If the scope breaks while Diane is using it, she will pay for the repair; otherwise the doctor is responsible. She also has purchased her own scaler, magnification loupes and headlight. When Diane is not at the office, the other hygienist, who practices full time, uses the light. For that reason, the doctor reimbursed Diane for one-half the cost of the light and supplies all the bulbs.
A few years ago Laurie attended a hands-on course to learn how to use a manually tuned scaler. She fell in love with the technology and convinced the doctor she practiced with three days a week to purchase it for her. Over the years she purchased a few extra inserts and her own set of magnification loupes.
When the office schedule slowed down Laurie increased the number of days she worked at another office. Laurie is a straight shooter. She felt guilty about being there fewer days a week and she was the only one who wanted to use this equipment. Laurie also wanted to use the scaler in the other office, so she offered to buy it. The doctor got scared and told her no. He was worried that she would leave his practice. Finally Laurie's schedule was down to one day a week. She made out a check for a fair amount and approached the doctor again. This time he accepted her proposal and happily put the money in his pocket.
Many of you know that I started buying my own equipment years ago. I started out getting a few of my own instruments. The operator chair in the office where I practiced was completely worn out and the seat pitch damaged so I felt as if I was going to fall out of the chair at any moment. By the end of every day I was exhausted. The doctor refused to get a new one and instead recovered the old one. When I realized that magnification loupes and a chair would help me feel better I went to the next dental meeting and ordered both items. I felt like I had just shot my wad! What was I thinking? Twelve hundred dollars was a lot of money and it was even more a decade ago.
The rest is history. My body is healthier and my mind is free to focus on what is important. Many times I have been paid a higher rate per hour or day, but that was not my goal. My doctor pays me well and gives me tremendous flexibility with my clinical schedule. That is what works for me.
Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing-education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by e-mail at [email protected].