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The HMO experience

Oct. 1, 2009
How to survive the ‘mill’
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How to survive the ‘mill’

By Eva M. Watson, RDH

Your next patient is running 20 minutes late, but you can still see him.” When I looked up from my patient to acknowledge the receptionist, she was gone.

“She always does that!” I continued to feverishly work the adult prophylaxis on my current patient. “Oh, man,” I thought. “I still need a check. My air/water is leaking, I still need to go over OHI with this patient, and she looks like she’s gonna deck me because I’m rushing her cleaning.”

Inside, I was crying and cursing. My poor husband was going to have to listen to me complain about how unhappy I am being a hygienist — again! “I can’t do 30-minute prophies anymore. I can’t!” I said to myself over and over again. It was only Monday and this was my first patient and I had 12 more to go. I was already 10 minutes behind schedule. This was as clean as I was going to get this patient.

“Okay! Let me polish and floss and I’ll let the doctor know you’re ready for an exam.” I think the patient had invisible heat rays coming from her eyeballs because I felt my brain melt after my last-ditch effort to make myself look professional. I felt sweat drip down the back of my neck. I wished the air conditioner was working properly. Wait … was it even working?

I’d heard of prophy mills and drill ’em and fill ’em offices while I was in dental hygiene school. I knew I didn’t want to work for an office like that. Yet I worked for an HMO office for three years when I received my license. I was so eager to learn and do all the things they taught me in school. That was the first year. I knew I was not doing the best job I could. A scaling/root planing patient would return and I’d only have 10 minutes to probe and scale because the patient would want to talk about why his or her gums were still bleeding. I only had 30 minutes.

For those of you who are wondering, that 30 minutes included radiographs, probing, scaling, polishing, OHI, waiting for the exam, and breaking down my room. For SRPs, I had an hour to 80 minutes for an FMX, SRP of two quads, charting half the mouth, anesthesia, scaling/ultrasonic therapy, Peridex irrigation, any Arestin needed, OHI, and breaking down my operatory, and sterilization. I did not have an assistant in my second and third years. When patients wanted to talk, they expected to be listened to, not rushed through a procedure, scooted out the door with half their questions unanswered, and a fake compliment trailing from their crazed hygienist, “You’re doing a great job! Just keep flossing!”

The second and third years were just as difficult, but I managed to shine through the proverbial dark clouds. I continually ran a few minutes behind but performed the best treatment I was able for the time I was allotted. I tried not to cut scaling corners. I connected with as many patients as possible. I utilized soft skills communication and never let patients walk out the door without making their next prophy appointment. The pace was grueling and the days were frustrating, but I managed to get through them.

Looking back on three years of what I thought were hair-pulling, exhausting, I-can’t-take-this-anymore days, I wouldn’t change any of my experiences — ever. Those years taught me how to work efficiently, purposefully, and perform well under pressure. I would not be the professional I am today without my clinical HMO experience. Would I recommend new graduates practice in an HMO facility? Yes! But proceed with caution! If you as a hygienist want to learn to practice efficiently, I say go for it. Treating HMO patients will force you to learn from experience, and learn real fast. Survival was my main goal when I was an HMO hygiene soldier. The following are tips and warnings for working “the mill.” Please be advised: The advice is based only on my experiences as an HMO hygienist. You may take it with a grain of salt and tell me to pack it up and go home, or you can read with an open mind. Not all capitation offices mirror my background … but I bet they come darn close.

Survival Tip 1: Arrive at work a half hour early.

After treating an average of 10 to 12 patients a day, I was utterly wiped out by the last patient and wanted to leave the second I was done. I tended to be a morning person so I knew that I could accomplish many tasks in the wee hours. When I arrived 30 minutes before my first patient, I managed to set up my trays, stock my room, turn equipment on, sterilize my instruments, review my charts, and most importantly, make a really strong pot of coffee. These were vital in achieving some semblance of organization. The last point was absolutely mandatory. I love caffeine.

Survival Tip 2: Use your ultrasonic scaler — ALWAYS!

I’m probably going to get a lot of flack for this, but when I realized I was not going to get more than 30 minutes for a prophy, I only used the ultrasonic scaler. It was essential to stay on schedule, so the use of a Cavitron kept me close to on time. Did I hand scale? Of course, but I was very selective in using it. When I spotted moderate areas of calculus I did not pick up the scalers. When a patient arrived 15 minutes late and I was expected to treat that patient, I cranked that ultrasonic sucker up and went to town. What would have taken 20 minutes with instruments took me half the time with the ultrasonic scaler.

Survival Tip 3: Perform OHI during the cleaning.

All hygienists’ time is precious as soon as our patients sit in our chairs. I had no extra time. As soon as I laid my patients back in the chair I began treatment and went into oral hygiene instruction. Patients held a hand mirror while I explained proper brushing and flossing. I used my ultrasonic tip as an imaginary toothbrush, instructed them how to brush, and went right into the prophylaxis. Regarding flossing, I asked patients to demonstrate their flossing method, praised or corrected their techniques, and flossed their teeth immediately afterwards. My oral hygiene instructions were brief and to the point. Once the patient was sitting upright, OHI was complete and the exam was underway.

Survival Tip 4: Turn over your operatory while the patient is waiting for their exam.

My operatory was designed so that my working counter space was directly behind the patient chair. Rarely did patients turn around and inspect what I was doing. I made small talk with them while I started to break down, wipe down, and set up for my next patient. I knew what items the dentist needed for her exams, so the air/H20 tip, mirror, Shepherd’s hook explorer, and a 2x2 gauze square were ready and waiting. Everything else, minus the patient chair, was prepared for my next patient. Once the patient exited my operatory, all I had to do was wipe down the chair and place a new barrier. My fellow dental hygiene colleagues reading this article may think it was rude to do this — that patients were still in my chair. Yes, they were, but they did not seem to mind what I was doing. That’s when the brief chit-chat was most useful. Soft-skills communication is needed in every practice situation, more so for capitation facilities. It definitely does not hurt to kill them with kindness if it means staying on schedule and having your patient load run smoothly.

Survival Tip 5: If an assistant is certified in coronal polishing, ask the assistant to do your polishing.

This tip worked very well when the doctor’s assistant was free to help. Not only was the dentist’s assistant certified in polishing, but she received a monetary bonus for every patient polished. Because of her additional compensation, the assistant made herself available to do my polishing when time allowed. As the dental assistant was doing her thing, I could use another operatory, if one was available. If no other rooms were open, I performed the break down/wipe down/set up for my next patient as the assistant polished. Teamwork is everything. Practices will fail without it.

Survival Tip 6: If you share the sterilization responsibilities, take a shorter lunch break to get it done.

You may be thinking, “This chick is nuts! I’m not sacrificing my lunch hour to do sterilization, no matter how many instruments are laying there!” I can feel the love all around me. But just hear me out. If finishing up with sterilization before eating lunch takes about 15 minutes, why wouldn’t you do it? So you miss 15 minutes of relaxing, eating, making phone calls, etc. Isn’t it better than the alternative, which is staying 15 to 20 minutes late after your last patient? I vote for the former. It’s a small price to pay. You’re keeping the day on track (or at least trying to) and your afternoon will involve clean instruments.

Survival Tip 7: Document hygiene notes during the examination.

Hygiene notes do not have to be a novel. I knew what I wanted to write and brevity was the key. I managed to log the basics and highlight any anomalous findings in a few words while the doctor performed the exam. Sometimes the dentist needed me to log her findings and it only took a couple of minutes, then I went back to completing my records. I rarely have charts waiting for me to write in. Even if you have oodles of charts waiting for your signature, don’t worry. You always have your lunch break! I know. I’m pushing it.

Survival Tip 8: If you must perio chart the same day with SRP therapy, chart only half the mouth.

Full mouth charting was my responsibility during my capitation days. If I planned on working on the UR/LR quads, I only charted those areas during that appointment time. The two other quads could wait. Again, that’s all I had time for. If you think you have enough time to chart all four quads and scale, then go for it! That’s less to worry about when the patient returns to have the other two quadrants root planed.

Survival Tip 9: Take a brisk walk.

This helps tremendously. I don’t always return to the office refreshed, perky, and brimming with enthusiasm, but a walk does clear my head. The fresh air (wait…does Chicago have fresh air?) coupled with a brief reprieve away from the office gives me a sense of renewal. The moment was fleeting when my first afternoon patient ran 15 minutes late, but there’s something to be said for “taking five.”

Survival Tip 10: Laugh. Laugh your butt off or you will lose your mind.

This tip didn’t always work for me. I’m a fairly intense, go-getter in the dental office atmosphere, so I was very serious most of the time. That did nothing for me. Once I learned that having a sense of humor might actually help my psyche, I tried to make light of my capitation days as best I could. I advise picturing anything extraordinarily stupid that makes you laugh and relish the moment. That will help. Would I go back to working in an HMO office? No. The schedule was much too grueling and I simply did not have the physical stamina to move that fast. Emotionally, I was drained to the point of sobbing. My attitude went completely south. I loathed coming into work and the dentists found my poor attitude too much to handle. Eventually I was let go from the practice. On the brighter side, I wouldn’t be the person and dental hygienist I am today without going through the HMO mill. I’ve become a more patient, likable, and efficient clinician.

For those of you employed in a capitation office who would like to remain with your practice, I hope my advice helps you. Many of us know how difficult it is to work in an HMO facility. Hang in there. For those in an HMO office trying to leave, do what’s right for your hygiene career. Only you know what’s best for your peace of mind.

About the Author

Eva M. Watson, RDH, practices at the Highland Park Dental Group in Highland Park, IL. She can be contacted at [email protected].