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Interpersonal communication, and the methods and modes through which it is achieved, has exponentially increased and diversified over the last 20 years. The concept of the ‘internet’ had long been theorized, in a similar manner to Jules Verne and the submarine, by a number of Americans in the 60s, but the actual creation of the worldwide web was achieved by a Brit by the name of Tim Berners-Lee in 1991. He created the first website and lit the touch paper on the information revolution or, as some may call it, the sociological devolution we currently reside in. Social media and smartphones have resulted in a net reduction of face-to-face interpersonal communication. This is largely due to the efficiency with which messages can be sent to hundreds or thousands and the lack of commitment that is required to achieve it. I am part of a Whatsapp group for Arsenal supporters where we disseminate the misfortune of our team's current predicament; this has largely replaced the banter of a drink on the weekend at our local pub. Instead of travelling to a mutually agreeable destination and finding somewhere to sit and poking fun at each other, we simply bash our screens with emojis, memes and GIFs. There is less original humour and wit than there was when we used to meet in the Black Lion all those years ago. This type of messaging and communicating is addictive – we are slaves (or slain?) to our phones. I am forever trying to dodge people on London roads who refuse to look where they are going and would rather be mesmerized by their screen. Phone addiction is rife and, in a similar way to other addictive tendencies, results in a dopamine hit which feeds our pleasure areas of the brain. Smartphone Apps such as breakfree and moment actually track how much time you spend on your phone and calculate the number of seconds, minutes or hours we spend. Download it and try them; you may be shocked at your own results!
Indeed, we find ourselves on tenderhooks after composing and sending an email that we eagerly await an answer for – ‘Why haven't they answered?’ ‘It's sent’ ‘They have it’ ‘Reply to me!’. Gone are the days of snail mail when the reply would reveal itself, depending on how efficiently Her Majesty's postal service was operating. Typed or written letters may actually be considered a novelty now.
What affect will this net reduction in face-to-face interpersonal communication have on our profession? When we treat patients, disgruntled or otherwise, we do not do this through a screen. When we type our notes, for the potentially litigious patient, we cannot add a Snapchat or an emoji to express the situation. Hence the devolution of face-to-face interaction may translate into an erosion of our ability to communicate with our patients effectively, with potential repercussions.
These digital changes to our everyday lives have been fairly stealthy for those of us that didn't grow up ‘with’ the internet and are normal for Millennials that have. The effect on how we access information on dentistry has also been fascinating and disturbing in more or less equal measure. Culturally, some may find discussing or, indeed, arguing clinical issues on Facebook or Twitter uncomfortable, almost peculiar, whilst others find it to be second nature. Indeed, there are generational differences in dentistry that are being magnified by digital media. Baby boomers and Generation X may frown upon Millennials and their openness and honesty in their communications and especially at their professional and social difficulties. Indeed, the former are more likely to have worked in times when dentistry in the UK was a ‘better’ profession to be in compared to now and may not appreciate how much harder it is to be a new graduate. The flipside, as someone who works on a daily basis with new graduates, is that the Millennial generation are very talented and extremely adept at learning and training.
An interesting aspect of social media and, more specifically Facebook, is the posting of clinical cases or even ‘ideas’ or ‘innovations’. All of ten years ago, clinical case reports would require the processing of photos, a write up and a peer reviewed process before being ‘published’. This process, having gone through it on a few occasions, is arduous and frustrating, but was hugely rewarding. Being ‘published’ fed the ego after months of hard work and effort. This pathway has been short-circuited by social media, where cases can be posted from the chairside almost instantly and reach thousands of people. Although not peer reviewed, cases may warrant dissemination amongst the dental community quickly and efficiently in this manner. In a worrying number of cases, some from these shores and the majority from elsewhere, the treatment of the patient has been less than optimal or even ‘wacky’. Most recently, an individual sandblasted a DIY screw (the B&Q variety, nothing to do with Nobel or Straumann) and placed this in the patient's mouth and ‘restored’ it. Thankfully, and rightfully, he was challenged by people from a number of different backgrounds and time zones. This was fairly sickening. There are YouTube channels where individuals purposefully seek out physical confrontations with groups of people to get beaten to a ‘pulp’. This is being filmed solely for the purpose of Youtube channel ‘views’. A part of me feels that wacky, peculiar or atypical treatments are portrayed to spark some sort of reaction or being lauded, as I doubt if any dentist would even consider IKEA spare parts (you know the ones that are left over after you have finished making the wardrobe) as suitable material for their own mouths!
The other, more concerning, aspect of case posting is that for advice on treatment planning in seemingly straightforward cases. In these instances, you may worry for the safety of the patient. If my orthopaedic surgeon took a snapshot of my knee and posted it on Facebook with the question ‘This knee looks a little too knobbly, any advice on how to manage?’ prior to taking a blade to it I would be very concerned. I could imagine spontaneously waking up from the anaesthesia and hobbling (or hopping) out of theatre if it were ever to arise. Despite this concern, there is huge potential – we can see rare and difficult to diagnose conditions and, in such cases, technology could be beneficial to patients. This may be even more relevant in areas of limited access to NHS secondary care services. Thinking of colleagues in Oral Medicine, ulcers and potentially cancerous lesions photographed in a controlled virtual network may really be a great initiative. This is already a feature of many postgraduate courses where formal guidance in a bespoke secure portal is available during the course and beyond.
At the other end of the spectrum is the seemingly flawless or ‘perfect’ case. Forget the quality of laboratory work, these cases have gingival stippling that mimics zodiac star constellations. Clinical excellence should be fostered and standards should be set for all to aspire to. The issue in a lot of these cases is that they tend to lend themselves to admiration or adulation (but in a lot of cases should be the technician!), whilst almost simultaneously sparking reflection in those of a (as yet), less developed skill set. Heavily buffed, perfectly realistic, glycerine-covered ceramic crowns on a black background is one very small aspect of dentistry – and is unlikely to be the most important one.
The posting of cases does also raise an issue dento-legally. Do patients realize that the photos of their mouths are going to be accessible to tens of thousands of people and commented on and potentially used for purposes other than they intended? The Montgomery case and consent points to outlining all ‘material risks’ with social media. How can a clinician detail these with the permanence of information being stored in the ‘cloud’ and the relative inability to control how the information can be used in the future?
As can be appreciated, where cases are posted, disagreements can arise. These instances can get unsavoury and potentially unprofessional. In my experience, disagreements can become a lot ‘spicier’ where individuals have either a vested financial interest in a product, company or training facility. In other instances, polarized ideals of treatment, such as invasive versus non-invasive aesthetic dentistry, seem also to be rather fiery. The verbal jousting can vary from noble gladiators to the less classy, but equally entertaining, Macgregor vs Mayweather. We can get quite drawn into the debates – some may even get the popcorn out where discussions progress deep into the evening. Other than aggressive cosmetic dentistry, the current fad of ‘edentulation’ (a slang word for dental clearance) and immediate implant placement is also something that sparks a lot of controversy. There are positives and negatives to be taken from these interactions. Social media is a great tool for freedom of expression. Dentists from all over the world with varying experiences and backgrounds can provide opinion for the benefit of all. Alas, due to the instantaneous nature of the conversations and the hundreds of people who are interacting, the process of moderation may not always be feasible or possible.
Due to the relatively immediate nature and magnitude with which people can be informed or contacted, social media is an incredibly powerful tool and, as with all tools, it can be misused for unscrupulous purposes. Old fashioned misrepresentation may involve making false claims at a lecture or on a plaque in a surgery. Now anyone can make any number of claims or misrepresent themselves whilst assuming that their online colleagues will never suggest qualification or substantiation on what is said or, indeed, typed. Social media is awash with self-appointed (or self-anointed) gurus in one form or other: an expert or other, supported by an online Mafiosi who defend every point made, drowning out other comments that may contradict the supreme ‘manifesto’. Impartiality may not be considered a virtue in some of these arenas.
Pretentious behaviour, portraying rich and lavish material spoils, is common online. Is this really a measure of success or merely an expression of lack of humility? Unfortunately, some may look upon such self-aggrandizing behaviour and compare and contrast with their own lives and careers. Dentistry is a profession of high achievers who have conquered many hurdles put before them throughout their careers, largely through academic or clinical challenges. Isn't it rather crass and ostentatious to be in people's faces on a daily basis showcasing these types of ‘achievements’ amongst a profession of supposed intellectuals?
Enough of the bad; more of the good. Through comments and expressions made online or the sharing of stories and humour, many have made some great friends through social media. We are not talking about ‘virtual’ friends, these are new friends that, without media, I would never have met or shared time with. Many colleagues have been able to reach out to help and advise individuals on their careers and, in some cases, guide through professional challenges. There is now, more than ever, a sense of ‘community’ amongst those users and this has manifested in many ways and not solely for the purposes of dissemination of dental information. Gym, film, football, and even a dental whisky appreciation group, allow for a sense of refreshing camaraderie amongst colleagues outside of clinical commitments. Group initiatives for job seekers within the profession has also been hugely beneficial to many and, where there are many professional uncertainties, provide avenues for career change through social media.
The most recent development, and I have to say the most admirable, is that of groups aiming to support dentists that are struggling at work through professional challenges or mental health issues. Dentistry is tough. We all feel it, regardless of where we are and what our chosen work environment is. There are difficult patients, difficult colleagues and, most of all, difficult expectations. This is all on a backdrop of challenging remuneration systems, a net increase in litigation and debt amongst new graduates. Admitting to issues is the first step in rehabilitation; it is the hardest and the most difficult. In a perverse way, the detachment that posting provides as opposed to openly talking to friends face-to-face might actually be beneficial in times of strife. It seems as though the need physically to speak to someone is still crucial, despite all the technological advances. Interestingly, through these ‘dental crisis’ groups, face-to-face group meetings of 25 people or more to share their problems and exchange advice have been spontaneously set up. A problem shared, ‘face-to-face’ as opposed to ‘facebook-to-facebook’, is a problem halved as they say.