A combination of expanded hygiene and a salary based on production can open up new horizons that can benefit the practice and the hygienist.
by John A. Wilde, DDS
The weeks don't fly by as blithely as they once did, Dr. Diluvial reflected as he absently toyed with some paperwork on a somber autumn Friday afternoon. Still, it was a good week. He had performed some fine dentistry he knew would enhance the lives of patients, some of whom had honored him with their trust for over three decades. He was tired, but with the pleasant fatigue that accompanies honest work. However, he awaited his final appointment of the week with a disquieting mixture of eagerness and dread.
There was a single rap on the door of his private office. Carol, who has been his receptionist almost from the first day his practice opened, stuck her head in, smiled, and announced, "Ms. Spring is here to see you."
He rose and greeted Aurora Spring with a warm hug. She'd been a patient of his since she was three, and was now a hygienist practicing in a nearby city, home for a holiday visit. He hadn't seen Aurora for several years, but she'd called the office a week ago and asked to meet with him. While their conversation had been cordial, he'd sensed that she was deeply troubled.
Aurora was wearing a stylish scarlet suit, white hose, and heels. A delicate fragrance engulfed her that reminded him of his wife's fabulous rose garden. Always vivacious, he'd watched her grow from a sparkling child, to a gangly teen, to the lovely woman before him.
"Dr. Diluvial, it's so good to see you! I've been visiting with Carol and some of the girls. Your practice sounds as wonderful as ever."
"Thanks Aurora." He gestured toward a steaming pot of tea and a tray of pastries. "We've prepared a small snack. We're celebrating the triumphant homecoming of a fellow dental professional."
Aurora grimaced…then poured a cup of herbal tea for the doctor and one for herself. Dr. Diluvial selected half a chocolate
Aurora took a tiny bite of pastry, as delicately as a cat, and favored him with her enchanting smile. "It's so kind of you to spare me this time. I hate to bother you, but I have a real professional crisis on my hands. It was the example of your wonderful office that led me into hygiene, so I couldn't think of anyone more qualified or appropriate to discuss my concerns with than you."
He nodded encouragement, concerned by her deepening frown.
"Hygiene school was tough, but I love what I can do for my patients. I deeply believe that gum tissues provide the basis of all oral health, and as research shows us more clearly every day, gingival health is vital to systemic well-being."
Dr. Diluvial smiled as he savored his chocolate treat and the soothing heat of the minty tea. "I couldn't agree more," he said, "but what's the problem?"
"Well…things are difficult in my office. I believe the dentist I work for is a good man. He provides excellent care and I enjoy the staff. But there seems to be so much tension. Everyone is rushed. Nerves are frayed. We seem to be constantly behind schedule. I know it doesn't have to be that way. I never had to wait to see you, and everyone here always seemed so relaxed and happy. Also, while my salary is acceptable, I have no benefits. And I haven't been given a pay increase since I started…while other staff members have had two raises."
Aurora's lip quivered as she added, "Scrubbing instruments, giving oral hygiene instructions, developing X-rays…it's getting tedious already, especially when I'm almost always running late. It's just not fun. I don't know if the office is to blame. Maybe I've chosen my profession unwisely. Whatever the cause, I can't see the bright future I've dreamed about."
The doctor had suspected something like this, and was glad he'd taken time to prepare. The fate of hygiene had been a matter of great interest and concern to him for some time. He lifted a file of documents from his desk and studied them as Aurora struggled to regain her composure.
"Yours is a pretty common complaint, and I feel a real blight to dentistry," he explained. "It's such a difficult, yet critical, job that hygienists perform, but it often can seem thankless…even unrewarding. Let's look at these articles and see if we can understand this problem from a wider perspective."
Dr. Diluvial then pointed to some figures he'd highlighted on the top document. "This 1998 practice survey shows the average hygienist produced $6,835 per month, or about $82,000 per year." He shuffled the papers quickly. "Now, this October 2000 survey states the average hygienist's salary nationwide to be $39,770."
Aurora studied the data. "What exactly do you mean? Do you think hygienist are overpaid?"
"Hardly!" he exclaimed. "I think they are underpaid considering the skill, difficulty, and importance of their work. But what percentage of hygienists' production were you advised that your salary should comprise?"
"I guess the figure I've always heard for compensation is around 33 percent," Aurora said.
He nodded in agreement. "But $39,770 is 46 percent of $82,000, or over $12,000 a year above the suggested norm! And, there are lots of other expenses besides the hygienist's salary, such as a portion of the rent, equipment, utilities, phone, staff time, and, of course, supplies dedicated to hygiene. Paying 46 percent for salary means many dentists are unable to break even in hygiene."
A deep frown creased Aurora's brow. "You're implying that losing money by offering hygiene services can be a cause of office stress. Then hygienists must make too much?"
He shook his head in vivid disagreement. "Not at all! You aren't paid enough, dentists often lose money, and too many patients get lousy service in a rushed and unhappy office where everyone can sense a vague frustration! The delivery of dental hygiene care hasn't evolved since the concept was first implemented. The problems are not with the dentist, hygienist, patient, or even the frequently castigated insurance company. A badly antiquated system is to blame for all the strife. However, we've refined a method that works better for hygienist, dentist, and patient.
"Melissa, our wonderful hygienist, switched to expanded hygiene years ago. The day she made the change to two rooms and working with a full-time assistant, her productivity increased 50 percent! We were able to immediately expand from seeing eight patients a day to 12."
"That's great!" Aurora enthused. I'm embarrassed to admit this, but I've kept careful track over the last month, and, with failed, cancelled, and unfilled time, I only have averaged treating about six patients a day ... or about half of Melissa's total! Even though I have no business background, I understand it's hard to justify my position based on six prophys a day."
"I'd say that's fairly typical," Dr. Diluvial said, "but it's certainly not the case in our office. Two years ago, we switched Melissa's compensation from salary to a percentage of her production. On the very day we switched, she increased production another 25 percent, on top of the 50 percent gain we'd already achieved from expanded hygiene!
"It seems so obvious now, but people gladly work harder if they can make more money. Melissa's assistant and one of our front-office staff are paid based on a percentage of hygiene production. When they aren't seeing patients, they aren't getting paid. These are serious and dedicated professionals who hate wasting time. We've averaged 26 minutes a day of open time so far this year, counting failed, cancelled, and unfilled time slots. We keep very precise monitors of unproductive hygiene time, because wasted time is squandered money for everyone involved."
Dr. Diluvial shifted papers again. "Here's a copy of the hygiene production monitors we keep. Melissa, her team, and I review them each month at our regular hygiene staff meeting. You can see that, in 1999, Melissa and her team's average production was $133 per hours or $1,064 per day."
"Let me see those figures, please," Aurora said. "So, on a 20-day month, like I work, you'd produce over $20,000 in hygiene alone! And you said the national monthly average was around $6,800? Wow! That's quite a difference." Her eager smile let me know the old, positive Aurora could sense opportunity. "Please tell me more about how you do it," she urged.
"I'm no visionary, and there are lots of offices more productive than ours," the doctor explained. Most of these ideas I owe to Dr. Joe Dunlap. Joe is an extraordinary dentist, writer, editor, speaker, and…I like to think – a friend. Our team heard him lecture for ProDentec – the folks that make the Rota-dent toothbrush – years ago. That day changed the entire way we treated hygiene patients forever.
"We were so inspired that, on the drive home from the meeting, our entire staff vowed we would no longer abide bleeding gingival in any patient. No more notes would be put in a treatment plan like, "Discuss perio and bleeding. Stress floss. Set appointment in six months for prophy."#39; That had been too much the norm in our office for years. We'd treat the active bacterial infection in patients' mouths until they obtained complete health…or told us to leave them alone!
"The next day, we began to offer four levels of periodontal care, and we quit "treating' disease with a prophy. Our recare visits were tailored by the patients' oral health needs…intervals anywhere from two months to a year…not just every six months when insurance will pay for it. All of the details of our system, including insurance codes, are in this packet I've copied for you."
Aurora's smile lit up the darkening room. "Dr. Diluvial, you've saved me again! I've been reading the want ads and came home to consider a new career. But I'm going back to work…armed with all your great resources…ready to change the world...well, at least the part of it that is my office! Thanks so much!!"
"It was a pleasure, Aurora," Dr. Diluvial responded. "It's sad dentists are so isolated. I love to tell others what we are doing, because everyone benefits. Hygiene is very profitable for the office, as it should be considering the time, expense, and effort it demands. I'm delighted to pay Melissa over twice what she had been making in a previous practice. I'm happy to pay her the increased salary because it doesn't come from my reduced profits. It's paid from the fruits of her outstanding efforts."
Aurora smiled. "I'd feel great knowing that I was a profit center for my office."
The doctor nodded in agreement. "And, in return, I'm glad to provide every device and convenience we can come up with to make Melissa's professional existence more fruitful and happy. That includes providing her with her own X-ray head, nitrous oxide, intraoral camera and the piezo-scalers she loves. Her assistant also helps with much of the tedious work you're already tired of."
"But how do patient's react to having an assistant work with them?" she asked.
"Well, Linda is great with people," the dentist continued, "and the hygiene assistant must be a strong people-person. Since we have two staff here for a total of 16 hours a day to care for 12 patients, each hygiene patient now has 80 minutes of staff time available instead of the standard 60. And we don't fritter away those precious minutes discussing the weather. That extra 20 minutes is more valuable time spent in education, building relationships, answering questions, and being sure no one ever feels rushed."
Aurora took the folder Dr. Diluvial offered and shook his hand affectionately. She beamed and waved as she energetically strode through his door. He smiled back. Helping this fine young lady find fulfillment within the noble profession of dental hygiene had been the pinnacle of his week. He just wished there was some way to get this important information into the hands of more dental health-care providers ...