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No Way! Not Me!

Feb. 1, 2001
Many dentists are in the dark about the amount of strife they cause in their practices.
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The following letter from a hygienist to her doctor/employer was created hypothetically, and sent to a cross section of approximately 15 dentists last spring. Each doctor was asked to imagine that the letter had been sent by his or her hygienist. The doctors were invited to describe how they would react; they were also informed that their responses might be published in an article.

We invite all hygienists - and their doctors - to read the following letter. Pretend that it is addressed to your doctor, personally. Imagine a comparable letter arriving from one of your other staff members. How would you feel? What would you think? How would you react?

As the responses reveal, most doctors are in the dark when it comes to understanding the world of the hygienist.

Dear Doctor:
It's easier for me to write this than it is to say it. I have worked with you for five years, and I couldn't be more proud to represent a man who cares as much as you do, and who provides his patients with the caliber of dentistry that you do. You inspire me every day! But some things have been on my mind, and I need to find a way for you to hear them.

You know that you have my respect. Do I have yours? Please know that I provide the best dental hygiene care that I possibly can in the amount of time allocated to me. When you ask me to "go over #14 distal-buccal," the embarrassment overwhelms my face. Is it really worth it, in light of the positive service I have just provided, to do this in front of my patient? I am also asking that you think twice before you impulsively pick up my curette and start scratching away at something I have left behind. Any minimal benefit gained will be greatly overshadowed by the humiliation I invariably feel when this takes place in front of the patient. I know it's my problem; I shouldn't be processing all of this as if I were a dental hygiene student being graded by my instructor. It should all be about what's in the patient's best interests, right?

The book Don't Sweat the Small Stuff advises choosing one's battles wisely. It's a winning proposition for everyone. If you absolutely must inform me of an area I need to go over, then write me a note as you leave - out of view of the patient. Hearing your appreciation on a regular basis in front of our patients will do wonders for our relationship and ultimately, wonders for the practice. I speak favorably of you to every person who sits in my chair!

Finally, I know that you want me to encourage our patients to schedule needed dentistry. If I bring an area of potential concern to your attention, and you do not consider it to be valid, be diplomatic when you verbalize your lack of agreement with me. Helping me look my best only makes you look your best. If my findings continually get "shot down," I can't help but retreat for purposes of self-preservation. An interactive, win-win dialogue between us enhances the likelihood of patients scheduling their dental treatment.

Let's talk soon about what we consider the priorities to be in the recare visit. I am not always certain that we are on the same wavelength. I know that we can reach a mutually positive solution.
Your Hygienist

Reactions from Doctors

Doctor No. 1: I'll assume that the hygienist's description of the situation is entirely accurate; that is, an independent third party evaluating the situation would totally agree with her to the letter. First, I would ask her to please pardon me for creating anything other than good feelings. I had no idea that my comments and actions were doing this. Our office should be a happy environment.

I would then ask her to sit down with me and figure out how to refine our communication to each other. Indeed, there are times when we in dentistry must sweat the small stuff. However, if we dentists are to expect exuberant loyalty from our staff, then we must reciprocate. There must be a way to suggest to the hygienist to take a second look at the mesial of #14 without indignifying her. We can easily establish verbiage that is far more palatable when I disagree with a tentative diagnosis.

It may also be the case that the hygienist is doing things that irritate me. This would be a good forum to iron them out. Perhaps a facilitator would be good here.

Doctor No. 2: Great letter! But I would be crushed to have received that letter in the mail. I try to promote a relationship with my staff that enables them to speak to me with candor. I respect all of my coworkers. We engage in two-way discussions and reinforce each other. I want them to tell me everything as soon as the patient is out of earshot. Secondly, I have never, nor will I ever, critique in the presence of the patient. If the hygienist missed a bit of calculus or if I overlooked a carious lesion, the world would not stop spinning. The name of the game is "mutual support." The patient must know that the team is the best and that every member of that team is the best.

All I have to do is look across the hall to find the subject of your letter. "Dr. Perfect" criticizes his assistants to the point of tears on an almost daily basis. Great letter. To the point. I never want to get one!

Doctor No. 3: (Condensed) My initial response is as if I just received it. My second response allows me the luxury of giving it a day to sink in. I'm certain, however, that anyone who reads the letter will think it is addressed to him or her personally.

My initial reaction to this letter is: I feel ambushed, and disgusted with the staff member who would think this about me. Why didn't she talk to me? I am furious - I don't know why the hygienist is reacting in the way she is ... Is she that concerned that my actions would cause her so much grief? When I see a problem, it is easier for me to pick up an instrument than to tell her where the problem is. If this was bothering her, why didn't she approach me sooner? These problems are not mine; they are hers. I do agree with numerous points, but I have been forced into a defensive position.

The following day, I have a totally different perspective. I agree with the hygienist's assessment, and I can see why she would not want to confront me. I would want to be treated in a similar manner if I had been placed in that situation. I know that I do not have all the answers and that maybe an old dog can be taught new tricks.

For me, avoiding a confrontation for one day has helped me see the light. Friday, it was all her problem. On Saturday, it became my problem - I asked her to accept my apology and to help make me a better person.

Doctor No. 4: My gut feeling about this letter is that either the dentist must be arrogant and unapproachable, with a "God" complex - in which case the letter is futile - or the hygienist is in too much awe of the dentist and too timid to speak her mind,in which case the letter would never be delivered.

Maybe I'm just focusing too much on the "five years." The overt message of the letter is excellent. We all need to work on building each other up. The unwritten message, however, is the fear of open communication and trust from the hygienist. The unwritten message would worry me more!

I would certainly want to improve the relationship with a staff member who was so loyal, yet felt I was so difficult to talk with. The best way to do this would be to follow through on her ideas in the letter.

The opportunity to read this makes you think about your own behavior.

Doctor No. 5: Well-written letter. I am very sensitive to these issues and go out of my way to avoid such circumstances. However, if I were in the hygienist's position, I would probably want to face the issue "head-on," one-on-one instead of voicing my concerns in a letter. The letter might create an even greater distance and allows the dentist to construct a reply rather than respond in an unadulterated, extemporaneous fashion.

If the hygienist doesn't feel comfortable with the direct approach, then there is probably more wrong with the relationship than what happened in the operatory. Most dentists are nonconfrontational; they are more likely to show their frustration regarding the perceived inadequacy of the hygienist in this indirect, triangulated way. Again, it would behoove the hygienist to deal with it face-to-face.

Doctor No. 6: First of all, there is a major communication problem in that office. If they have been working together for five years, this should have been ironed out a long time ago. Everyone has a different breaking point, and even though it took her five years I respect her for addressing the situation. Not that it is an excuse, but maybe he didn't realize what he was doing wrong. Now that he is aware of his actions, let's see if he learns. (I'd be curious to see if there is a similar situation with the assistant.)

Although the letter hits on a few points, she doesn't follow through on the time issue. If more patient time would eliminate her mistakes, then something should be worked out. However, what if her self-evaluation is not accurate and additional time would not solve anything? The dentist is still at fault because he should have helped her improve or dismissed her from the practice. Whatever the reasons for the inadequacies, the patient's oral health must come first!

He is very lucky to have an employee who takes pride in her work and cares enough about the office to write this letter. Many employees just quit, or even worse - they stay and make life miserable for everyone.


I found it interesting that many dentists hone in on the fact that the hygienist waited five years to speak up, and that she chose to write a letter rather than confront face-to-face. Who knows why she did what she did? Who cares? This is a trip down Hypothetical Lane, and the prevailing issue must be: What can dentists do with this information now that they have it?

Most doctors will never receive such a letter. The objective here is to stimulate both doctors and hygienists to look closely at the dialogue and interactions that take place during patient exams.

Pay special attention to the hygienist's words in the last paragraph. She says, "Let's talk soon about the priorities in the recare visit. I am not always sure we are on the same wavelength." This is so true. All too frequently, doctors and hygienists have different expectations as to what should take precedence during a continuing care visit. One doctor may be most concerned that his hygienist sells dentistry. Another may want all patients to leave with tooth surfaces as smooth as glass. And so on.

Any conscientious hygienist is generally doing the best that she can in the time allocated. Doctors need to make certain that they have set forth clear expectations regarding their priorities. Open, ongoing communication is integral to a positive working relationship between the two parties.

Eileen Morrissey, RDH, MS, is a consultant in Perrineville, N.J. She can be contacted by phone at (732) 446-9079 or via e-mail at EEmorrissey