Don’t you cringe when you hear patients say, “It’s just a cleaning”? Patients just don’t seem to value their hygiene visits as much as we would like them to. Fees for hygiene services are often questioned, particularly if they do not fit the insurance model. Appointments are cancelled. How can we change the way people see hygiene visits?
Patients often come with a “car wash” mentality, but sometimes so do we. So much to do in a hygiene appointment! So many tasks to accomplish. Boxes to check off. Procedures to complete. Relationships to rekindle. Treatment to recommend. Instruction to deliver. Can’t keep the next patient waiting! Can’t keep the doctor too long from a restorative patient! Must keep the schedule full. Must meet hygiene production goals.
Can we step off the treadmill for a moment? Can we briefly put aside the model, systems, and assumptions currently in place about the hygiene visit to focus on the essence of what we want to accomplish?
What if you organized each visit around asking yourself these Three Key Questions?
This part of the hygiene visit is a check in with the patient. It is designed to begin each appointment with curiosity about who this patient is today. If it makes any assumptions, it assumes they are different today than they were the last time we saw them. It goes beyond the routine, “Any changes in your medical history? Any problems or concerns today?” Patients by and large come prepared to dismiss those questions. What about: “How has your health been since I saw you last?” “What have you been noticing in your mouth since the last time you were here?” “How has that exercise program you were working on been going?” “What have you been doing to take care of yourself lately?”
The way we ask questions matters, but I am less invested in the question, than in the conversation. The patient’s response to your question is a beginning of a dialogue not the end. It can be an opening into learning more about who this person is and what is important to them now.
Our dental charts say, “Discussed perio disease,” “Discussed cracked tooth,” etc. Missing is information about what the patient said in the “discussion.” I think the note would more accurately read “Informed . . .” Information without dialogue is a missed opportunity. Follow information with an invitation to engage, “What comes up for you when you hear me describe these conditions?” “What are your thoughts about that . . .?”
This is the conversation about the current clinical conditions. As a practicing hygienist, I saw the clinical exam as a data gathering task, not a dialogue about health. I thought my job was to examine, record, and report what I saw. It took me many years to see the opportunity to engage the patient; to get them “into their mouths” and increase their ownership of the conditions we discover.
As you begin your exam, put a mirror in the patient’s hand and ask them to hold onto it in case you have questions. Look for an opportunity to ask a question as soon as possible. “Can you bring that mirror up here for a moment please? I’m noticing bleeding between these two teeth although I don’t see it in these other areas. Have you noticed that when you brush here? When you floss?” Wait for a response. Help them see health where you see it. All the areas where there is no bleeding. All the places where they are very effective at removing deposits, as well as where they may be missing.
As you co-discover clinical conditions you can create a dialogue about how to best use your time that day. “Based on what we are seeing here today I think I can remove those hard deposits that have built up on your lower front teeth, gently clean between the teeth and gums around your molars where we saw some bleeding, and polish off the tea stain you were concerned about. How does that sound to you?” If they agree you might also say, “Would you like me to see if I can help you find a way to be more effective getting rid of the bacteria causing the inflammation around your molars?” The dialogue part happens when we wait for an answer and follow up with more questions as needed.
When something other than a “cleaning” is indicated, this is the time to have that conversation. Not when you have run out of time. Not when the doctor comes in. Not when you are dismissing them. Not when they have forgotten what you discovered together in the exam. Inviting a dialogue now saves time and energy in the long run, and avoids potential misunderstanding and conflict.
Getting agreement on what happens next is so much easier when the patient has been engaged in the assessment process. And the best time for this is during that dialogue, not when they are ready to walk out the door. If we see a need to decrease the interval between now and their next appointment, it’s easy to have that conversation when they are looking at the current conditions. “Based on the amount of inflammation we’re seeing here I’m concerned that your body has not been able to fight off the bacteria gathered over the last four months on its own. What are your thoughts about that?” In dialogue we are open to wherever that conversation may take us. If the patient asks what you mean, you can say you think that it would be better to see them again in three months rather than four to assess how they are healing, followed by “How does that sound to you?”
If a patient says no to coming in more frequently you can ask what they think they can do to reduce the inflammation you discovered together. They may say they think they can floss more regularly, or ask about other options for home care. Yes! Now you have a partner!
Organizing hygiene visits around these three conversations is not as difficult as you may think. You can still stay on schedule. You can still maintain your relationship. You can still meet production goals, for hygiene and for restorative treatment. You have time. You have the lifetime of your relationship with that patient. If you stay focused on helping patients move toward health, and stay patient with the process you have all the time in the world.