Aug. 1, 2012
I work in a public health facility. We work four 10-hour days and see all kinds of patients, including fee-for-service, Medicaid, insurance, and patients covered by grants.


Dear Dianne,

I work in a public health facility. We work four 10-hour days and see all kinds of patients, including fee-for-service, Medicaid, insurance, and patients covered by grants. When I was hired, we were expected to see 10 patients a day. However, due to the high no-show rate, the front desk started scheduling 20 patients a day with the hope that 15 will actually show up. Needless to say, if even 15 people show up, I'm overwhelmed! I have two operatories to work from but no assistant. One of the operatories has no ultrasonic scaler. I feel like I'm compromising the standards of care that I was taught in hygiene school. I need my job, but I dread going to work. I'm only 30 years old, and I'm already having back and neck problems and headaches. The saddest part is that I'm sorry I chose dental hygiene as a career. Is there any hope for this sorry situation?
Katie, RDH

Dear Katie,

Listen to me. There's always hope. But let's dissect the issues, because you've brought up several problems.

A 10-hour day is a long day, and it is crucial for you to take care of yourself physically. It's likely that the back and neck problems are related to posture and ergonomic issues in your workspace, and your headaches could be stress related. The best investments you can make for career longevity are a pair of high quality loupes and a headlight. Not only do loupes improve your visual acuity, they also help your back and neck by forcing you to sit straighter. I recommend Designs for Vision™ for many reasons, including their high quality optics, personalized customer service, and 100% made-in-America products (

If my math is correct, a 10-hour day means you're seeing patients for nine hours with an hour for lunch, which means 540 minutes for patient care. If you were seeing 10 patients, this allots approximately 54 minutes for each patient (540/10 = 54). However, by ramping up the number to 15 a day, the math changes dramatically - 540 minutes/15 patients = 36 minutes for each patient. If you count 10 minutes for operatory turnover, that only leaves 26 minutes per patient. If all 20 people show up, this leaves only 17 minutes per patient - 540 minutes/20 patients = 27 minutes - 10 minutes (operatory turnover) = 17 minutes per patient. It is not humanly possible to maintain this pace and provide anything close to high quality care. It's a cattle drive. In these situations, hygienists pray for a no-show.

The stress you're experiencing from overscheduling can be reduced with better scheduling techniques. While it's true that many of the clientele served in public health facilities are hardship or indigent cases, their lot in life does not grant them permission to abuse the care being provided to them at reduced or no cost. If there are no rules in place, people will make up their own rules. Some ground rules need to be established. Here are my suggestions:

1. A frank discussion should take place with every patient (or guardian) about the scheduled visit. "Mrs. Smith, please understand that this time has been reserved for you. Our time is valuable in that many people are in need of our services. You're privileged to be able to obtain care here. However, if you miss your appointment without proper notification, we will not be able to see you in the future. Do you know of any reason why you would not be able to keep this appointment?"
2. Every patient must provide at least one telephone number for contact. If no phone number is available, then a patient must call your office the day before the visit to confirm that he or she is coming. Otherwise, the appointment will be given to someone else. Inform the patient of this.
3. Patients with a history of no-shows should be warned of the new policy regarding "disappointments." "According to our records, there has been a pattern of disappointments in the past. Please be careful that this does not happen again because it will jeopardize your privilege here."
4. There are extenuating circumstances that may require bending your rules, but that should be the exception.

It is obvious that the person who decided to overbook the schedule due to anticipated no-shows does not understand (or care) about standards or quality of care. You need to schedule a conference with the highest decision maker who can do something about the problem. I recommend a conversation like this: "Since I'm licensed by the state to perform dental hygiene services, I am mandated to deliver a certain level of care. The problem is overscheduling of patients. With so little time, it's impossible for me to adhere to the standards set forth by my licensure. I'm coming to you with the problem in hopes that you can implement changes that will allow me to serve our patients better and not jeopardize my license." Bring the list of rules that I've suggested to curb the problem of no-show patients. If you think about it, the no-show problem is at the core of your issue. If that problem is corrected, the schedule should become more predictable. Overbooking is a poor way to deal with people who disappoint.

Also, if you're expected to see a high volume of patients, you need assistance. If you help the decision maker understand how an assistant could help you be more productive, less stressed, and deliver high quality care, your chances of getting an assistant are greater. Assure the decision maker that you value your position, and you want to serve the organization and patients to your best ability.

If your suggestions fall on deaf ears, you have options. First, you could find another position. Second, you could file a complaint with the state dental board. Dental boards are mandated to see that quality of care standards are not being violated. Third, you could do nothing and allow your career to be shortened by the physical, mental, and emotional trauma to your body from overscheduling, unrealistic expectations, and impossible working conditions. It's obvious that the third option is not the best choice.

I have much empathy for hygienists who work in public health or indigent care facilities. My experiences volunteering in this area in my own state opened my eyes to the overwhelming dental needs of people who struggle financially. Right here in the richest country on the planet are millions of people with dire dental needs. Unfortunately, basic dental care has become an unaffordable luxury for many. While foreign missions are noble and honorable, dental professionals do not need to travel far to find an ever-increasing population of indigent people desperate for dental care. I urge all dental professionals to become involved in dental outreach efforts right here in America.

All the best,

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is a professional speaker, writer, and consultant to dental practices across the United States. Dianne's new book, "The Consummate Dental Hygienist: Solutions for Challenging Workplace Issues," is now available on her website. To contact her for speaking or consulting, call (301) 874-5240 or email dglass [email protected]. Visit her website at