Make the best of it? or .... head for the state line?

July 1, 2003
Alabama hygienists with a college degree represent an alternative to preceptorship.

by T.K. Allen

Recently, RDH magazine received an email from Alabama that made the editor take notice. It wasn't an angry defense from an outraged preceptor. It wasn't even another dentist defending what he and his colleagues had done to hygiene in Alabama. It was a hygienist ... with a degree ... and a question: Why doesn't RDH ever write about college-trained hygienists in Alabama? "How about an article on the alternative to preceptorship?" she suggested. And so we decided to look into this rare phenomena, the Alabama hygienist who holds a degree.

Cassandra Henderson, RDH, of Remlap, Ala., is tired of having Alabama hygienists automatically thought of as preceptors.

"There are not too many of us," she confesses. "I was one of 11 graduates from the Wallace State Community College Dental Hygiene Program in 1996. This was the first class of dental hygiene students to graduate from Wallace State. That was also the same year that UAB (University of Alabama at Birmingham) graduated its last class of bachelor-degreed hygienists."

Henderson had been attending college for a year, studying physical therapy assisting, then sports medicine. Realizing her major was impractical for jobs in her local area, she decided to enter the dental field. She knew an assistant who told her about the ADHP (Alabama Dental Hygiene Program), or preceptorship program. With this in mind, Henderson interviewed with several dentists for an assistant position, but when she mentioned wanting to become a hygienist, the interviews always fell flat. Taking the initiative, she went to Wallace State Community College in Hanceville to enroll in the Assisting Program to get her CDA certificate. As fate would have it, the program director for assisting, Kim Gay, was also one of the key people for getting the two-year hygiene program started in Alabama. Having earned a master's degree from UNC Chapel Hill in dental hygiene, Gay felt it imperative that Alabama be given an alternative to the ADHP.

"Ms. Gay told me that the first year for dental hygiene candidates at Wallace was starting in the fall. Since that was my goal all along, I figured I'd get my license on my own and not wait for a dentist to tell me when I could become a hygienist. I graduated in 1996 with an associate's degree in applied science of dental hygiene," Henderson said.

She is now working in a periodontal office four days a week. I asked her if Alabama dental patients were aware of the ADHP.

"Most are not aware of it or the training required for a hygienist in other states. I believe they think it's like this everywhere. They would think twice if they were told their dentist had been trained in an environment similar to the ADHP."

When asked about how the ADHP brought about the anemic payscale for Alabama hygienists, Henderson chanted the mantra of many dentists in Alabama.

"The ADHP! Once, a dentist said to me, 'Why would I pay you more when I can find a girl to clean teeth for less?' I wonder if he cares more about a good hygienist in his office or saving money," she said. "I think the January issue of RDH proved that with its salary and benefits survey."

Henderson believes a college education is worth the effort no matter what the degree. Even with the precious little compensation given degreed Alabama hygienists, she said she'd do it all again.

"While I was in school full-time, I also had to work full-time from 4:00 to 11:00 at Wal-Mart to pay bills and tuition. Looking back, it was the toughest time of my life, but I wouldn't trade it for the life lessons learned."

Henderson tells me that even though she is a degreed minority in a crowd of preceptors, as long as she doesn't bring up the subject, she gets along fine. She stresses that she is not attacking ADHP hygienists personally. It's the program that's flawed in her view. Anyone wishing to fully serve the public with standardized clinical instrumentation skills and professional knowledge in her field deserves better. The ADHP also suggests that hygienists in Alabama will be forever under direct supervision, foregoing the freedoms other states now enjoy. Henderson says she plans to work in Alabama for a while, but she'd like to relocate and practice in another state someday. She can do that, unlike her ADHP counterparts.

Jane Doe, an RDH who wishes to remain anonymous, received her bacherlor's degree from the University of Alabama in Birmingham. A native of Alabama, Doe already knew about the low salaries paid to hygienists in her state. Still, she chose a four-year degree. She has served in her state dental hygiene association and is working in a general dentistry office in Birmingham.

She has some interesting views on preceptorship. Unlike most of the readers of RDH, she has actually worked with preceptorship program (ADHP) hygienists. She has gotten to know quite a few of them and treats their regular patients from time to time.

"I have come across some very talented preceptors," Doe says. "Some are conscientious and dedicated. But these are the ones who have gone through the preceptorship program and, feeling it wasn't enough to equip them adequately, have taken the initiative to finish their training. They've gone a step further, taking additional coursework to complete their training. Their scaling skills are possibly on the level of a college-trained hygienist, but most of them didn't emerge from the program that way. With the ADHP, every hygienist gets a different instructor, her boss, a dentist who usually has little or no time to teach clinical instrumentation. Dentists get precious little training in dental hygiene during dental school anyway. So the consequences to the patient are calculus that has not been properly removed, but burnished onto the tooth with a polisher, making it even more difficult to remove during the next visit. And it sometimes isn't. Patient education is rare and oral cancer screening is nearly nonexistent. What I'm trying to say is, there are college-trained hygienists who take their jobs seriously and try to be the best they can be in their profession. Then there are those degreed hygienists to whom their profession is just a job, a way to pay the bills. There are all kinds of preceptors too. For some, the program is just a ticket to a pay raise. But for others who graduate from the program, there's dissatisfaction with their training and a feeling that they're not ready to treat patients. Those individuals either find a way to self-educate or go back to assisting ... or, worse, go ahead and practice on the unwary public."

Doe recommends that those wishing to pursue a career in dental hygiene in Alabama go the college route. It's only a two-year program at Wallace State. (The four-year program at Birmingham was shut down since Doe graduated, giving the entire state of Alabama the choice of either Wallace State or preceptorship. Could this have been intentional?) In the ADHP, one prerequisite is that a candidate has one year of experience in a dental office. Combining that and one year in the program, they'll invest the same amount of time as they would for a two-year degree. But the outcome will not be the same.

LeeAnna McFarlin, RDH, got her associate's degree in 1999 from Blinn College in Bryan, Texas. It took more than three years for her to earn this degree after satisfying all the prerequisites that Texas requires. The average salary in Texas at the time was $200 per day. But when McFarlin moved to Birmingham in 1999 and got her Alabama license, this degreed hygienist started work at $120 per day. It was a shock, but she was glad to find a job working for a dentist who didn't also expect her to assist. (In a preceptorship state, it is taken for granted that the hygienist can assist.) She also noticed that in a preceptorship state, there was no real monetary compensation for a college degree. College didn't seem to matter. Still, McFarlin did field a question from a practicing preceptor on where an 11-12 Gracey was supposed to be used.

McFarlin later moved to Huntsville, Ala., where she found a wonderful office that treats her like "family." She's making a couple of dollars more per hour and that helps with her three children and a husband in law school. She enjoys her work and her patients love her. Job satisfaction makes up for that lost Texan salary.

Carol Elgin, RDH, is also a degreed hygienist living in Alabama. But unlike McFarlin, she works out of state. A 1968 graduate from the Indiana University School of Dentistry, Elgin is a firm believer in equipping health professionals with the best possible training.

Before Elgin left Indiana, the only two topics that seemed to spark an interest in her hygiene meetings were independent practice and preceptorship.

She shares, "We knew about Alabama's program. That's why I told my husband that I would move anywhere but there. As fate would have it, that's exactly where we landed."

Having become an Alabama resident, Elgin considered getting an Alabama license ... for two minutes. Her skills and training were worth $27 an hour in Indiana, plus lots of benefits. She couldn't see applying for the opportunity to receive the lowest pay in the country. Every other state told her she was worth more to the dental practice than that. So she opted to apply for a Tennessee license instead, salvaging her self-esteem and her accustomed paycheck.

"I leave the house at 6 a.m and spend an hour in the car getting to work in the morning," Elgin tells me. "It's a 97-mile round trip from Huntsville, Ala., to Winchester, Tenn., but it's worth it. I work four days a week at a professional office that compensates me for my skills, training, and what I bring to the practice. It's the perfect office, but it took a while to find."

I asked her to what she attributed Alabama's low hygiene salaries. The answer seemed obvious to her. It is a statewide version of the good-ol'-boy system at work, creating hygienists it can control financially, professionally, and geographically. It is total, state-run ownership with an emphasis on saving money.

While still in Indiana, Elgin treated a 30-year-old man with Class III periodontal disease. He left her office that day saying, "She cares more about my mouth than I do!" Over time, he followed her to three successive dental offices, being genuinely impressed with her scaling expertise, patient education, and treatment results. Elgin knows some preceptors care just as much about their patients. The difference lies in the training they received.

Some hygienists who have moved to Alabama have decided it's not even worth working there. One Wallace State College graduate I contacted is in the process of moving from Alabama to Tennessee. She is delighted at the prospects of getting paid what she is worth to a dental practice. More power to her, I'm sure she'll be missed. Other hygienists hesitated to speak out because of possible repercussions. Being a rare minority in a state bent on furthering preceptorship, their very jobs may be at risk by speaking their minds. Their reluctance is understandable. Many degreed hygienists living in Alabama did not return the call from RDH for an interview. Rocking the boat would not be healthy for their careers. One degreed hygienist completed the interview only to withdraw her comments the next day. There is fear and precious little freedom of speech when preceptorship dominates a state. It is instigated and perpetrated by those who hold the key to employment. Is this the American way?

One hygienist told me of treating a regular patient in an office that employs preceptors. The patient had had a scaling and exam a mere six months ago, but no bitewings had been taken for two years. After taking X-rays, the hygienist could see why scaling was so difficult. The X-rays uncovered subgingival Class III calculus jutting in spicules from the interproximal areas of the teeth. The hygienist then had the unpleasant task of informing the dentist of the patient's condition and the suggested treatment plan. The dentist had to tell the patient she needed four sessions of deep scaling with anesthesia or she would suffer tooth loss. The patient was shocked, confused, and understandably angry. The dentist was embarrassed and quickly left the hygienist to answer the many questions that followed, placing her in a very awkward situation. Sadly, this is not the first time I've heard this scenario.

Another degreed hygienist, after practicing in many states, remarked of the camaraderie among the preceptors she has encountered in Alabama. As she temped in several locations there, she felt accepted in almost every office, unlike some offices in other states. There was no power struggle, no cold shoulders. The preceptor hygienists were very willing to help her find things, fill her in on patient information, and generally make the "new girl" feel welcome and appreciated, even if she didn't have an Alabama accent. In most preceptors, she saw a genuine desire to do good, professional work.

"This is what concerns me," she says. "Given adequate training, these individuals have the drive and the brains to meet and exceed professional standards in any state. How many of these health professionals were talked out of going to college by their bosses in favor of the program, the dental board's statewide agenda?"

I met one such person. Both she and her husband are still angry that she took her employer's ill advice. "Why spend all that time and money in college when you can be out making money in a year with the program?" he had asked her. She submitted to going through the program, but was appalled at the lack of time and training her employer invested in her. She managed to pass her clinical exam, which isn't difficult when politics are in your favor, but now she's limited to practicing hygiene in Alabama. Not paid enough for all the stress her unpreparedness had caused her, the preceptor left that office, disillusioned.

She concludes, "You'll get letters from preceptors boasting about what excellent training they've received from their employers. They're the fortunate ones. But those who feel they've been led down the garden path for their employer's benefit dare not speak out. I say those who have a heart for hygiene deserve better. Their trusting patients deserve better too."

Degreed hygienists in Alabama must have a different mindset than others not living in preceptor-oriented states. I'm told that for many it's like mission work, job satisfaction in place of a respectable paycheck. These hygienists, feeling the futility of their situation, are left with three choices: try to make the best of living with preceptorship and the resulting lowest salary in the nation, stay home, or head for the state line.

T.K. Allen is the pseudonym for a frequent contributor to RDH.