by Dianne Glasscoe-Watterson, RDH, BS, MBA
I graduated from hygiene school six years ago. Currently, I work in a two-doctor, three-hygienist practice. The problem I am writing about has to do with one of the other hygienists in the practice. She has been practicing for more than 20 years, and it is logical to think that with all that experience she would be a superb clinician. I wish it were true! The fact is, the quality of her work is poor. She rarely uses her power scaler, and her instruments are always dull. Her sharpening method seems strange to me — she keeps the stone stationary on the table and moves the instrument across it.
Recently, I was asked to complete a root planing patient that she had begun. The chart notes indicated she had completed both quadrants on the right side. I found so much subgingival calculus that I wound up rescaling both right side quadrants at no charge to the patient.
I do not know what to do about this situation. Should I mention something to the senior doctor? Should I say something to my coworker directly? I feel very uncomfortable saying anything to her because of our age difference. Should I just live and let live? I want to do the right thing.
The fact that one graduates from a dental school or hygiene school does not automatically guarantee a lifetime of clinical competency. Graduation indicates the clinician has reached a certain level of competency at that point in time, which ensures a foundation of knowledge on which to build. It is like building a house. We have to start with a foundation and build the structure from the ground up. Some people keep on building and adding to their house through the years, while some never progress very far beyond the bare basics.
Providing competent clinical care means learning new things and moving forward as the knowledge base grows and changes. If I continued to practice like I did in 1978 (the year I graduated from hygiene school), I would rarely use ultrasonics except on gross calculus cases; I would not wear gloves; I would still believe mechanical friction is required to remove plaque; I would never use anesthesia; I would still be doing the old gross scaling/fine scaling routine; I would believe that the patient’s level of oral hygiene would determine success or failure; I would be ignorant of the role of host immune response and the many systemic factors associated with periodontitis; and I would believe that bleeding is always a sign of disease.
When it comes to complete calculus removal, the fact is this: rarely, if ever, do we remove every last spicule. (Brayer WK, et al. Scaling and root planing effectiveness: the effect of root surface access and operator experience. J Periodontol. Jan. 1989; 60(1):67-72.) Even periodontists will admit that laying a gingival flap and being able to see the root surface directly does not ensure complete calculus removal. If we think we have removed all the calculus, we delude ourselves. Remember this: it is always easier to see the dirt in someone else’s house than in your own house, meaning it is easy for us to be critical of other people’s work.
However, there is a difference in leaving a few little spicules and leaving large chunks of easily detectable calculus. What you described sounds more like the latter scenario. We can only speculate about the reasons for such incomplete calculus removal, such as dull instruments, incorrect instrumentation, etc. The most important consideration in this discussion is patient care. It is our licensure mandate that we treat our patients with a level of competence needed to help the patient attain a high level of oral health. If we cannot do that, we need to refer the patient to someone who can.
One way to look at this situation is by approaching the dilemma as if you were the one leaving the calculus. If I were leaving so much calculus behind that my coworker had to rescale the areas I had recently scaled, I would want to know about it. How can I fix something that I do not know is broken? How can I improve if I do not know there is a problem?
I do not feel involving the doctor would be the answer, at least initially. What can he do? He did not see the problem firsthand. If he discussed the problem with your coworker, he would have to say something like, “It has come to my attention that you are leaving excessive calculus deposits…” The coworker would know that either you or the other hygienist had brought the matter to him first without consulting her.
Here is my suggestion on what to say:
Mary, something happened the other day that I think you should know about. I have given this a great deal of consideration and have wrestled with whether to say anything or not. I believe you would want to know and have a right to know. Do you remember a patient named xxxxx? I was asked to complete his RPS because he had to change his appointment. The chart indicated you had completed the right side scalings. However, I had to rescale the right side because of missed calculus. I know I don’t always get it all off either, but I just thought you’d like to know. I hope you will take this in the spirit it is offered, and that is as your friend.
This is certain to be a shock to your coworker, but she needs to know. This situation will demand as much tact and grace as you can muster. Always consider how you would feel if you were the other person. The fact that she is older should not prevent you from helping her.
Telling her is the hard part. Afterward, you may get an opportunity to help her with her sharpening technique. Also, you may get to help her expand the use of power scalers. My favorite inserts are the thin magnetostrictive inserts that can be used on high power, such as the Burnett Power Tip® by Parkell or the new Dentsply insert called THINsert®. It sounds like your coworker has allowed her clinical skills to stagnate over time. We all need to continually challenge ourselves to become better. When we rest, we rust.
Personally, I have never met a dentist or dental hygienist who feels he or she does substandard work. I believe most dental professionals take pride in their work and feel they have provided valuable services to their patients. However, it is no great revelation that all clinicians do not attain or maintain the same level of competency. When someone’s clinical competency becomes questionable, patient care suffers. Doing the “right thing” in this situation means calling attention to a problem that needs to be remedied in an effort to ensure the delivery of high-quality patient care.
About the Author
Dianne Glasscoe-Watterson, RDH, BS, MBA is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe-Watterson for speaking or consulting, call (301) 874-5240 or e-mail [email protected]. Visit her Web site at www.professionaldentalmgmt.com.