Preceptorship works, and the state?s own hygienists gladly tell you why ? but beware the voice of dissension.
Mark Hartley, Editor
Hygieinists are noted for their OpeopleO skills, carefully choosing tact while communicating with others. But here?s how a hygienist can experience a failure to communicate with a OcolleagueO from Alabama: Haughtily turn up your nose to a preceptor-trained hygienist. Any perceived snobbishness doesn?t sit well with residents of a state with the motto, OWe dare defend our rights.O The motto, by the way, was adopted in 1939 ? 75 years after the Civil War ? so it?s not an old battle cry that needs to be updated. Alabama hygienists strongly defend their rights to call themselves hygienists.
OI am a hygienist!O one Alabama reader emphasized with bold strokes and exclamation points while responding to a survey conducted by RDH. She is a graduate of the Alabama Dental Hygiene Program (ADHP), as the overwhelming majority of the state?s hygienists are. She proudly pursues a career as a hygienist, and what hygienists from the other 49 states think doesn?t really matter much. She?s legally a dental hygienist.
Some of the ADHP graduates are more tentative in being defensive, though, and many of the OtraditionalO hygienists living in Alabama downright loathe what OpreceptorshipO has accomplished. The survey alluded to above polled 1,641 RDH readers in Alabama, and 207 responded. Seventy-one percent of the respondents are ADHP graduates. The objective of the survey was to encourage Alabama hygienists to offer opinions about preceptorship in their Oown words.O
Any Alabama resident who suddenly thinks, OI wonder what I?d have to do to become a hygienist,O can go online and search the Web pages for the American Dental Association (ADA) and the American Dental Hygienists? Association (ADHA). The results of searching both Web sites lead to the same destination ? Wallace State College in Hanceville. The college offers a two-year associate?s degree program, the only OaccreditedO program in Alabama.
The ADHP thrives without such Internet referrals, because it recruits primarily from the ranks of dental assistants. In most cases, dentists motivate their chairside assistants to enhance their education by participating in ADHP. Although Oon-the-jobO training is part of the program, ADHP also includes classroom instruction and passing an established testing system. In exchange, the dental assistants earn more income and gain the prestige of being a licensed hygienist.
The ADHA is adamantly opposed to preceptorship. The dental hygiene association, for example, states in its position paper: OProviding a complete prophylaxis E is a complicated skill using a razor-sharp instrument E [treatments under preceptor-trained hygienists] run a greater risk of jeopardizing a patient?s health.O
The ADA does not publicly endorse preceptorship, referring to two-year or four-year accredited programs as criteria for the training of hygienists. However, various resolutions adopted by the association?s House of Delegates over the past decade do reveal support of initiatives to study the profession?s manpower needs for this century. Some solutions suggest elevating dental assistants into a stronger role in the hygiene operatory. On the other hand, it?s also been suggested that the duties of hygienists be expanded in the future.
Preceptorship has been subjected to criticism and even ridicule from the dental hygiene community, including RDH.
The safety of patients, as addressed by the ADHA above, is not the only issue at stake. Other points of contention are:
Y Increasing access to preventive care because of shortages of traditionally trained hygienists.
Y Questioning the capabilities of general dentists to provide Oon-the-jobO training.
Y Influencing hygienists? salaries.
Y Allowing interested candidates an alternative to receive appropriate training.
Y Strengthening political control over the dental hygiene community.
RDH invited its Alabama readers to comment on these issues in a survey mailed last summer. The magazine promised to allow the readers to speak for themselves and to present comments in an objective manner that would not appear to be merely more Obashing by outsidersO of ADHP graduates. Since ADHP candidates dominate dental hygiene in Alabama, as well as the responses to the RDH survey, they take the floor firstE
The ADHP hygienist
A dental assistant employed with a sponsoring dentist for at least one year can become an ADHP hygienist in a year?s time. They spend approximately 200 hours in a classroom on weekends and work full-time as an assistant/hygienist trainee under the guidance of a sponsoring dentist. The total cost of such an endeavor, including licensure, can be under $1,000. The cost can vary simply because candidates spend quite a few weekends in Birmingham for the classroom lectures and tests, meaning travel and lodging has to be budgeted for assistants who live far away from the central Alabama city. In contrast, a two-year or four-year program requires at least 1,000 hours of classroom instruction and 600 hours of clinical instruction. Even with variable tuition rates, most American hygienists likely dedicate more than $1,000 to their training and licensure.
If nothing else, ADHP has opened doors to dental hygiene that otherwise would have been considered too costly or time-consuming.
A 1983 graduate commented in the survey, OAs a young lady of 20, I was most appreciative for the opportunity to advance to a career that I felt I was suited for. I was thankful for the faith that my doctor placed in me. He was always challenging my mind, asking me questions, and showing me firsthand clinical diagnoses that you could never forget, because you?ve seen it in real life.O
Several readers said the ADHP program is flexible enough to coordinate the demands of personal life with professional training. A 1987 graduate said, OI am very proud to have graduated from the ADHP. It was a way that I could attend school to further my education and goals, to become a dental professional, and, at the same time, work and be a mother to my three children.
OIt was a hard course that required a lot of study time, but I could return back to my office to put to work my knowledge of the procedures. It was a good mixture of classroom and hands-on.O
A 1996 graduate added, OThe ADHP allowed me as a working mother ? who could not afford to quit working to go to school full-time ? to become a hygienist.O
A hygienist employed at the University of Alabama at Birmingham cautions against being misled about the OflexibilityO of the program. She said, OThe requirements for the ADHP are very strict and enforced to the letter. You are not allowed to miss any of the sessions. You have to maintain a certain grade to pass. You will not pass if you are one point short of the set grade. You have to treat a required number of patients ? both children and adults E Dentists must attend a course before they are allowed to have an ADHP student work in their office.O
Some dentists apparently prefer to have a direct hand in shaping the skills demonstrated in the hygiene operatory. A 1991 graduate said, OMost doctors prefer trained hygienists ? ADHP as opposed to a dental hygiene college. Too many extra courses are needed at a dental hygiene school ? you never need them.O
The value of Ohands-onO training in comparison to the academic environment was emphasized repeatedly by ADHP graduates.
A 1998 graduate said, OI came from a small practice where I received one-on-one training, and I feel I was able to get more training and experience than if I were sitting in a classroom.O
A 1991 graduate added, OThe training that I received as a chairside assistant and the daily interaction with patients proved much more valuable than Western Civilization 101 could ever be.O
A 1999 graduate said, OA (dental hygiene) professor has an entire classroom full of students; a dentist only has one student. Other hygienists are belligerent. I feel that?s because they wasted two to four years in a classroom trying to learn what we were able to in a year.O
Several questions on the survey addressed the quality and quantity of training offered under ADHP.
A 1995 graduate of the program, who had worked as an assistant for 14 years, commented, OPeople who don?t even know us or how our training occurs, depict us as backwoods hygienists and think we have gotten our training from a matchbook! We use the lessons we learn daily as we train. It tends to put hygiene into more of a perspective when you are actually hands-on. The dentists who we work for are very capable and helpful in our training; they are involved with every aspect as we learn.O
Another reader commented, OADHP students are required to complete about 256 hours of instruction at UAB (University of Alabama at Birmingham) School of Dentistry by the same professors that teach dental students. So we are not totally trained by our own dentist.O
A third reader said, OThe ADHP student gets more clinical experience. Clinical training is of much importance in practicing dental hygiene. Doctors help with the academics between classes and carefully evaluate the clinicals.O
A 1993 graduate said, OEvery dentist whom I have ever worked for is a perfectionist and will instruct properly and very well ? better than text books.O
Specifically, the survey focused on the sponsoring dentist, not the UAB staff. Many American hygienists remain skeptical about the abilities of dentists to train a hygienist about preventive or periodontal procedures. In addition, skepticism surfaces about the amount of time required for working with a trainee, since dentists also must maintain their own levels of productivity with restorative procedures.
Two common ways around the productivity problem are the cheaper wages paid to trainees and to train during a practice?s normal day off.
OA dentist?s wage for ADHP hygienists is usually reduced during the training period to compensate for slower productivity,O 1995 graduate said.
Another reader commented, OI began my clinical training on family members on Fridays when the office was closed. I was fortunate to have an excellent teacher and close supervision.O
A 1989 graduate pointed out, OUsually, a seasoned hygienist aids the doctor in overseeing the training of hygienists. The doctor gives his pre- and post-op exam as he would with any other hygienist. This allows him or her time then to consult and educate without interference to his practice.O
Some readers reported not-so-fruitful experiences with the hands-on training. One reader said, OI pretty much learned everything I know on my own. I feel most dentists in this state have only been interested in money.O
A 1994 graduate commented, OThe dentist who trained me spent about an hour of his time with me (not all of that hour at one time).O A 1991 graduate added, OI do think that most doctors are qualified to evaluate the progress, but few will donate the time.O
A 1985 graduate said, OI think the ADHP should monitor the dentists more in these programs.O
In addition, one ADHP hygienist noted the temptation associated with Ocheap labor.O OMost doctors see a student hygienist only as a means of having someone he can pay less during the training period,O she said. OThis leads to a great number of hygienists leaving the office where they were trained.O
Another reader added, ODoctors view ADHP hygienists as a dime a dozen.O
A 1996 graduate, though, observed, OThere are dentists who only look out for the mighty dollar, but they are the dentists who normally don?t want to miss work or receive the mandatory training (required of sponsoring dentists). Most dentists are honest with patients and explain the program.O
In regard to hygienists? income, Alabama usually ranks near the bottom of the RDH Salary & Benefits Survey. Does preceptorship influence such statistics? Many ADHP graduates point to the overall low wages earned by the state?s workers and believe hygienists are still fortunate.
A 1990 graduate said, ODental hygienists in Alabama may not make as much as others from other states, but for Alabama our salaries are definitely above what most people make in other professions.O
A 1994 graduate added, OI make $17 an hour, 29 hours a week. Pretty good for country life!O
ADHP graduates overwhelmingly believe the quality of their training leaves them on the same playing field with other hygienists in the country. ADHP hygienists recently lost the privilege of being able to take the national boards. Earlier this year, a provision was approved that would have permitted it, but that was later rescinded. Nevertheless, the survey questioned readers about how they think ADHP graduates would fare on the boards.
OI invite you to test us! You may be surprised,O a 1987 graduate challenged. She continued, OSchool-trained hygienists may have a slight edge in terms of knowledge straight out of school, but as far as five to 10 years later, you will find ADHPs are very knowledgeable.O
A 1984 graduate projected, OScores would probably be lower for ADHP hygienists in academics, but about the same for clinical.O
Preceptorship has not diminished the quality of dental care, ADHP graduates assert. They feel Alabama?s dental patients are in good hands ? theirs.
OI feel that the overall effect of the ADHP program has filled a need in the state,O a 1993 graduate said. OI feel that I provide a good service to my patients and carry seriously my responsibility of watching out for their oral health.O
A 1996 graduate said, OPatients from other states comment on how friendly, yet professional, we are. One patient from Texas had never been told she had periodontal disease.O
A 1997 graduate said, OI grew up in Illinois and have lived in Alabama for 14 years. I wish that every state would get smart and provide the program. It works!O
A third reader proclaimed, OWe are three miles from a military base and about half of my patients are affiliated with the military. I am told daily by them how much they appreciate my skills and how in another state they had a bad experience.O
A 1991 graduate said, OThe proof is in the pudding. My doctor holds me accountable for my patients. I make judgment calls, and he trusts me. That puts his neck on the line.O
Although she was apparently unaware of the Wallace State College program, a 1992 ADHP graduate presented a voice of dissension: OAlabama needs a two-year associate program for hygiene and to do away with preceptorship. You will just have to get the dentists behind it. The salaries are low because the doctors don?t want to pay a national board-certified hygienist when they can have the same production and have lower salaries. But, in the long run, I think the patients may suffer.O
Trained the old-fashioned way
It?s easy to understand why the hygienists who obtained associate?s or bachelor?s degrees from Alabama colleges feel strongly about the impact of preceptorship. They feel they have personally witnessed the shortcomings of the Alabama Dental Hygiene Program in both patient care and their own pocketbooks. Twenty-two of these readers responded to the RDH survey.
This section focuses on two of the responses. While the majority of respondents Ofilled in the blanksO to the survey?s open-ended questions, these two hygienists, who both completed four-year programs that were once offered in the state, took the time to write separate letters. RDH feels their comments are revealing.
The first hygienist noted, OSome ADHP dentists/instructors spend a great deal of time with their ADHP students, developing the clinical skills. These dentists allow the students time to observe and practice before they begin seeing patients E The ADHP students who have this degree of supervision develop very good clinical skills.
OUnfortunately, this is not the typical scenario. The ADHP students are issued their Ostudent permit? when the program begins in July. This permit allows the students to treat patients during their year of Oschool.? Many times, the dentist/instructor will schedule patients for the student before they have had any classroom or clinical training on instrumentation. When a dentist maintains his or her own full schedule, there is little time to train a dental hygiene student during office hours.
OThe problem with the ADHP program is that there are no clinical criteria to assure that the student is prepared to begin treating patients E The ability and willingness of the dentist/instructor to train an ADHP dental hygiene student varies greatly. The dentist/instructor only has to attend a four-hour certification course every five years to enroll an ADHP student. Some dentists abuse the program by enrolling a student every year. The student/employee is paid minimum wage during the year while seeing the same number of patients and bringing in the same production as a fully licensed hygienist.O
Unlike other degreed hygienists, this particular reader favored incorporating ADHP graduates into organized hygiene, stating, OI would like to see ADHP-trained dental hygienists receive full ADHA membership, so that they have access to any resources that will make them better dental hygienists E To provide the citizens of Alabama the best dental hygiene care possible, we need to encourage the ADHP hygienists to pursue any professional development that might be available. Many ADHP graduates are aware of the limitations of their training, and they want to improve their skills.O
The second reader?s comments included the following: OThe requirements of passing such a program do not compare to the four-year commitment of a bachelor?s degree program. No one disputes this. Unfortunately, the end result is the same for both ? the right to practice dental hygiene. Based on my experience, the pay is the same.
OSo what is the advantage I hold? The only thing that sets me apart is the right to practice in other states. If this is extended to ADHP graduates, then the whole nation would recognize and accept this level of academic achievement and expertise. Moreover, should other states offer such a preceptorship program, dental hygiene education and clinical skills would be dictated solely by the dentists, which would result in lower pay and minimum to no benefits. Why would this trend be attractive to any state, not to mention the nation?
OWe all feel our form of [accredited] education is the most effective. You may ask why I do not leave Alabama. I have fallen in love with this beautiful state and wonderful people, and have an employer I deeply respect. Alabama is my home.O
From the outside, now inside
Degreed hygienists who move to Alabama generally express hope that they find an employer who values the training associated with a degree, or they retire or cut back their hours. Without question, the Oout-of-townerO is the harshest critic of ADHP. For example, the RDH survey asked if readers have noticed any Oserious mistakes E in treatment or patient managementO by ADHP graduates. The out-of-towners were quick to criticize:
Y OInadequate medical histories; no clue as to what an oral cancer exam is; don?t get me started on all the subgingival calculus left, even after a one-hour, four-quad root planing.O
Y OSubgingival scaling is near nonexistent with the ADHP; thus, they are ? by lack of skills ? a source of periodontal disease.O
Y OLack of patient education, lack of knowledge about treatments available for the patient, inadequate scaling and root planing.O
Y OFailure to probe. A dentist ended up in a lawsuit. He lost the case because of the hygienist.O
Y OUnprofessional statements written on charts and general lack of professional attitude.O
Y ONo short-term mistakes, but probably long term in the treatment of perio disease because of lack of detection and proper cleaning skills.O
Y OInadequate health histories, incorrect use of instruments, incomplete scaling.O
Y OLacerated gum tissue which makes it much worse for the patient that they are Olearning? on.O
Y OOnly lots of subgingival calculus that was left for years, and the patients had bi-annual cleanings.O
Y OUnnecessary discomfort due to poor instrument adaptation, tissue damage, and lack of adequate tissue response due to poorly performed scalings.O
Y OTwo hygienists did perio on a woman with implants. They were overseen by two dentists. None of the four knew special instruments were needed. The woman lost the implants ? body rejected them.O
Y OThe inability to remove subgingival calculus; therefore, the patient ended up needing periodontal treatment due to neglect.O
Y OOne ADHP gal in our office couldn?t chart caries or take correct perio readings on patients. Another couldn?t take a good radiograph to save her life ? causing excessive radiation exposure.O
Y OI had one RDH ask me to show her how to scale/root plane after she completed the program. Another RDH asked me to show her how to take a FMX after she was certified.O
Alabama dentists would likely argue that at least some of the criticisms from above could be leveled at many hygienists from other states. It?s clear, however, that 38 of the 40 Oout-of-townersO responding to the survey believe ADHP training is inferior to the training that they received.
One transplant wrote, OI have worked in an office where the dentist has Otrained? several women, and I know for a fact they were not given quality training, not thoroughly checked after a prophy and scaling, and not told what they did wrong or right. We were always busy with full schedules. The doctor didn?t have time, and I never heard him correct the trainee.O
A 29-year veteran originally from an adjoining state commented, OI am in an office where I?ve seen four girls trained under the ADHP program in 10 years. I am not impressed. I would call it Opracticing? on patients, not educational training. There is very little time set aside. They just want production.O
A 16-year veteran added, OI have worked in offices where an ADHP trainee was training. There is no dentist training them. The only training in the office that the ADHP gets is from other hygienists.O
Although most of these degreed hygienists expressed dismay over low salaries in Alabama, a few said they were sought out, and paid well, by dentists who wanted them.
One reader commented, OI have noticed that the dentists I?ve worked for have a greater degree of respect and treat hygienists who hold college degrees much more professionally. Whereas the ADHP-trained hygienist is just another support person in the office to run the profit-making end of business. The ADHP-trained hygienist sees her job as a money-making process instead of a professional service to treat people and provide care.O
A 13-year veteran from an adjoining state said, OIf there were concerns over the public?s well-being and the public receiving the best possible care, there would not be an ADHP program at all. The concerns in Alabama are about money! Why should a young woman bother with college when she can go the quickie route with the dentist encouraging her on? The whole preceptorship issue is money-based.O
The RDH survey asked all of the participants about what factor is the primary reason Alabama hygienists earn less income. The results indicated that:
Y 47 percent of ADHP graduates attribute lower income to the argument that all Alabama medical and dental personnel earn less in the state.
Y 28 percent of ADHP graduates believe lower income is a result of lower fees or because patients tend to be more financially challenged.
Y 22 percent of ADHP graduates said the ADHP program itself is responsible for the lower salaries.
On the other hand, 96 percent of Alabama hygienists with a degree said the ADHP is responsible for the lower salaries.
The readers were also asked about the Ooverall effect of ADHP on the dental hygiene professionO in the state. The survey?s results reveal:
Y 55 percent of ADHP graduates believe the program has Oimproved access to care, as well as quality.O
Y 93 percent of those with a dental hygiene degree said ADHP has Odiminished professional integrity.O
Finally, Alabama hygienists were asked if the ADHP has influenced their long-term outlook for their career. The results indicated:
Y 83 percent of ADHP graduates Olook forward to a lifetime of working as a hygienist.O Only 31 percent of the degreed hygienists answered similarly.
Y 45 percent of the readers with a hygiene degree expressed Osome regretsO about their career choice, and 24 percent said they would probably retire from dental hygiene sooner than expected.