Professional Standards, Personal Responsibility

One of the best parts of being a hygienist in a dental practice is the opportunity to meet and relate to individuals in all age groups and from all walks of life. Urban practices in high-rise buildings have a different style and patient population from solo practices in the suburbs or in rural areas, but they all have one goal in common: excellent patient care. The responsibility for that care transcends the obvious and routine dental hygiene scraping, polishing, and examining. In a profession where trust is earned and personal care is expected, hygienists are held to professional standards of care, but have an even greater responsibility to understand what impact they have on the total health of their patients.


This article presents issues that are relevant to the hygienist’s role in meeting patient needs that are beyond conventional clinical hygiene procedures.

THE NEED FOR MEDICAL HISTORY REVIEWS AND UPDATES
Evaluation of the information contained within the medical history is cursory in many practices. While the information has ramifications for the well-being and health of the patient, and in some cases may impact the safety of the staff, too often the review is regarded as “just one more thing to be completed during the appointment.” The pressure to follow procedures, set the room up, build communication links with the patients, probe for pockets, scale, polish, take x-rays, complete the examination, and break the room down as OSHA suggests leaves little time to actually probe into medical health issues that might be indicated by the information on the form.

MEDICAL HEALTH ISSUES: DRUG THERAPIES
Professional standards would indicate that a complete review of the patient’s medical history needs to be accomplished, changes noted in the chart, and attention paid to specific items that can impact treatment needs. As a simple example, patients taking aspirin, coumadin, ginko biloba, ginsing, garlic, or a newer drug called Plavix should be aware that bleeding issues abound, and the physician should have input prior to the appointment. Is it a standard of care for you to understand the implications, or is it a personal responsibility?


As a professional, are you aware of the ten most prescribed drugs in the United States last year and why they are indicated? Do you see the same drug information on form after form without paying attention to the drug or the disease it may be treating? The population is aging, and patients will be taking more drugs as they age. According to the latest available information, the largest number of prescribed drugs will be taken to manage heart disease, congestive heart failure, and hypertension, and to lower cholesterol levels.1 Patients with the former conditions will likely be taking ace inhibitors such as Lotensin, Vasotec, Zestril, and others. Treatment protocols would include the taking and recording of blood pressure, and may include stress reduction, the use of oxygen, and an awareness that syncope could occur if the patient rises too quickly from the chair. Patients taking drugs to lower their cholesterol levels such as Zocor, Lipitor, Pravachol, and Baycol should have their vital signs monitored at each appointment, and the practitioner should be aware that angina or myocardial infarction may occur. 

The second category of drug therapy is for depression. Patients on this type of therapy may be taking the medication for clinical depression relating to a specific incident, or as a therapy to treat the hormonal imbalances of menopause, as well as a host of other reasons. Drugs of this type include Wellbutrin, Prozac, Paxil, Zoloft, or Effexor, and patients report side effects such as xerostomia or an unpleasant taste in their mouths. Potential medical emergencies in the office could include cardiac arrhythmias and/or hypertension. 

Further down the line, and as the population ages, drugs for the treatment of various types of arthritis pain become more commonly seen such as Celebrex and Vioxx. They also may be prescribed for severe pain resulting from dental or orthopedic surgery. Anti-inflammatory drugs such as ibuprofen and naproxen (NSAIDs) may also be indicated for mild to moderate pain. Incidentally, prolonged bleeding time may occur in patients undergoing this therapy. Medical emergencies arise when patients suffer an acute asthma attack following administration of the drug. 

The 7th edition of the Dental Therapeutic Digest has a complete listing of prescription products, uses, contraindications, and possible medical complications, and can be obtained through their website at www.dental­digest.com. It can be used as a quick source for the latest drug information or as a reference guide.

HERBAL AND ALTERNATIVE THERAPIES
Many patients and dental professionals are not aware that herbal therapy may have implications and contraindications with regard to dental and medical treatment. Probing for this information is important. For instance, patients taking echinacea at the first sign of a cold may be unaware that the herb works by stimulating the body’s immune system used to fight off viruses. According to the Nutrition Action Healthletter, March 2002, taking the herb as a preventive measure doesn’t seem to work. Patients should know that allergies to ragweed, daisies, and asters may indicate an allergy to echinacea, a plant from the same family, and patients who suffer from autoimmune diseases such as lupus or rheumatoid arthritis may suffer a flare-up if the immune system is stimulated.


Information on the use of ephedra for weight loss is plentiful. While it increases the metabolism, it simultaneously increases the risk for heart attack and/or stroke. For the opposite reason, patients taking kava for its sedative effects may suffer an increase in the sedative effect during general anesthesia, and should tell their physician prior to any surgery. St. John’s Wort dilutes the effects of drugs needed before, during, or after an operation. Valerian acts as a sedative and may increase the sedative effect of anesthetics used during surgery. (Stopping the herb abruptly, however, may lead to withdrawal symptoms.) 

Professionals understand that knowledge is important, but personal responsibility goes further as it seeks to understand the power that comes from knowledge and use it in everyday interactions with patients. It is your responsibility to assist pa­tients in linking dental health to total health. Too often, the dental office is not considered “primary care.” Even though there are established and documented connections between oral health (or lack of it) and diabetes, heart disease, and low-birth-weight babies, pa­tients may see your treatment as secondary to other healthcare needs. In fact, there are patients who consider day surgery to not be surgery in the conventional sense, and they may not even tell you that a heart procedure was performed. Not only that, because of the improvements in out-patient surgery, the procedure may have been performed just days earlier!

THE IMPACT OF GOVERNMENTAL REGULATIONS
As professionals, we are well aware that the impact of OSHA and blood-borne pa­thogen/infection control standards has been massive. Changes were instituted im­mediately, and sterilization processes changed the way instruments and procedures were performed. Compliance dictated that disposable equipment was developed, that personal protective equip­ment was made available for personnel, and that anything that could be disinfected and/or sterilized was appropriately treated. This included bags, wraps, and autoclaves that would not damage instruments and/or handpieces, and disinfectant solutions that were sprayed, wiped, and shot through hoses. Many practitioners thought it was overdone, and in some cases perhaps it has had that effect.


However, as the information was disseminated, it had the simultaneous effect of raising the level of expectation of care standards for both staff and patients. It is rare for a patient these days to question the use of gloves, masks, or gowns. Many practices choose the highest level of sterilization, and have used it to their advantage in marketing to their patients. Standards of care have changed. Your level of care has risen accordingly.

Because we are on the subject of government regulations, the focus this year is on the protection of private, personal health information both as it relates to your practice and, in the larger sense, as it relates to the transmission of this protected information to insurers, other healthcare professionals, pharmacies, etc. As the pressure to comply with the incredible number of HIPAA regulations increased, many of the initial regulations were challenged and diluted by pressure from healthcare associations, such as the ADA, other organizations, and individual health-care providers. The first draft of the regulations as they related to patient privacy suggested that sign-in sheets could not be used, that calling a patient by name in the reception area was not allowed, and that all treatment areas where patient discussions would be taking place needed to be soundproofed. Thankfully, pressure continues to have the regulations make access to healthcare easier rather than making it more difficult. (The ADA HIPAA manual presents the latest information and provides access to updates as they occur, along with necessary forms needed to keep your practice in compliance.) 

Regulations continue to abound with regard to the safekeeping of healthcare information. The HIPAA regulations scheduled to go into effect in April of 2003 are making the requesting of information a “signature” event. While the debate continues on the “why’s” of the need for stricter control, the die has been cast and compliance is not an option. Patients will now be told that you have medical information which can be transferred by phone or electronically when you speak to specialists, insurance companies when requesting payment for services, and pharmacies when prescriptions are written and filled. While this is nothing new, your patient’s level of awareness is being raised. Con­fidentiality of patient records and private healthcare information was the impetus for the documentation, and the order of magnitude for compliance increases as the size of the practice increases. As a part of this process, patients will now be asked to sign a form acknowledging that they understand your office has private healthcare information and that it will be used for treatment and payment purposes. Patients probably knew this all along, but now they will have to sign that they have been made aware of the consequences of sharing that information. In addition, they will need to sign that they understand that you will make every attempt to secure their information. The ad­vances in electronic billing that have been so successful in staffing, expense control, and reimbursement are a factor of concern, most especially in the medical setting. 

Large healthcare facilities such as hospitals and medical clinics are going to have a more difficult time meeting HIPAA standards as there are more regulations that directly affect them. It has been known for some time that sign-in sheets are not private, and the unscrupulous can use the information for illicit purposes. For instance, in large pediatric facilities parents who are feuding over custody of their children have access to appointment information that could place these same children in jeopardy. In the wider arena, the regulations make sense and were not designed to penalize a private practitioner nor make access to healthcare more difficult for the patients. In the short run, after the groaning is over, these, like other regulations (remember the furor over wearing gloves?) will be absorbed, and dental care will continue. 

In retrospect, does it seem unrealistic for you to protect private medical information that patients share with you as a professional? As a patient in any healthcare practice, do I want my personal information shared with the high-school person who files charts on a daily basis? No! Access should always be restricted to those “with a need to know” and for whom a review of the information is important as a part of their care. The HIPAA regulations work to assist the patient in building confidence that you are protecting their private information and the purposes under which it is being shared.

STAFFING AND FACILITY DESIGN
With regard to staffing, professional practices have long understood that information about patients should not be shared outside the office. HIPAA is now making it clear that information should only be shared when necessary within the practice, and that patient conversations should be private and privately held for anything more than routine discussions.


Open bay hygiene areas, once regarded as state of the art, present challenges for both patients and staff. Redesign is not mandated by the HIPAA regulations, but confidential conversations should not be held where others can easily listen. In that environment, treatment should be rendered quickly and conversations limited. However, professionals should be attentive to subtle indications from their patients that something may be wrong. Obvious abuse aside, young children and adolescents have privacy needs which should be respected. Quiet rooms or closed hygiene areas should be made available.

YOUR DIRECT ACCESS TO PATIENTS IS IMPORTANT
Hygienists have more direct access to their patients on a routine basis than anyone else in the practice. Children gain confidence and learn trust through care given by the same provider at each visit. Subtle changes in a patient’s overall health can be noted and followed in twice-yearly intervals. It is a re­sponsibility of staff members in your office to be aware of changes taking place and the possibility that heathcare is suffering. It is precisely through the trust built over time that children, adolescents, and adults share joyful and sometimes painful information with you. As an “outsider,” patients sense your objective caring and may lean on you for support when others turn inward. As a professional clinician, you have been trained for the former—as a person you may need to learn the latter.


A doctor recently told me of an incident within his practice. A college student, away from home for the first time, had some swelling in the region of the submandibular salivary glands. His friend convinced him to see her dentist. X-rays were taken, head and neck palpations were done, and an oral cancer examination was performed. The patient, 18-years-old, was worried about a tumor and was desperately seeking an answer. A referral to an oral surgeon was made, and the search for the cause of the swelling continued. CAT scans were performed, more x-rays, more questions, more lab tests, and the possibilities escalated to Hodgkin’s lymphoma. Through all this, the patient was told to contact the oral surgeon whenever he needed an update or for comfort. Many telephone conversations ensued, even after office hours. Throughout the diagnostic process, the oral surgeon continued to give close personal attention to the patient, and keep the referring dentist fully informed.

This is an example of personal responsibility on the part of the dental professional that goes beyond what may be defined as standard of care. Does this type situation happen every day? No. Should you expect this on a rare occasion? Yes. Should you be open to the possibility that patients have other needs besides those expressed within your practice expertise? Yes!

CONCLUSION
Please sit back for a minute and wonder at the level of responsibility you share for your patients’ total well-being. Beware of just “going through the motions.” Do not take this responsibility lightly. It is a reflection of the confidence your patients have in you as a professional and as a person they trust. All those years of training, school, practice labs, and clinic never prepared you for the one time you may be the person who truly makes a difference in a patient’s life.


Reference

  1. Spolarich AE. The ten most prescribed medications for 2001. Access. 2002; July.

Ms. Cary is the president of Creative Solutions, a dental consulting company specializing in the growth and development of dental practices and their teams. She lives and works in Atlanta, Ga, coaching, training, and enjoying the uniqueness of consulting as a career with many options. She has worked with many solo-, group-, and hospital-based dental practices and residency programs, helping them reach their potential. Presently her focus is assisting practices in the midst of growth, change, and transition, streamlining systems, and moving staff members through its processes. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .