Dental burnout – is social media a help or hindrance?

Stress, Burnout and Depression

Although there is an overlapping relationship between Stress, Burnout and Depression, it appears that there is commonly a progress from excessive, prolonged and often unanticipated stressors and the development of Burnout. Burnout has become accepted as a distinct psycho-pathological entity separate from, but often related to, Stress and Depression.⁴

Again a prolonged or untreated period of Burnout is likely, in more susceptible individuals, to progress to clinical depression.⁴ Stress is an inevitable component of any profession and, indeed, Payne suggests that Moderate Stressors (Challenging Demands) can lead to enjoyment and satisfaction, in the medium term, and a sense of Achievement, feeling of Adequacy and high Self-Esteem, in the long term.⁵ He suggests, however, that Strong Stressors (‘Excessive Demands’) can lead to Anxiety, Depression, Exhaustion and a Loss of Self-Confidence in the long-term.

In a longitudinal study, where new dental graduates were surveyed in the first year of practice and again 6 years later, Gorter et al, using the Maslach Burnout Inventory (MBI), found that, of the several areas of dental practice for which new graduates felt unprepared, only Technical Skills and Financial Management declined over time (from 29% to 19%; and 42% to 39%, respectively), while all other aspects increased, leaving Legal and Insurance matters (61%); Practice Organization (57%) and Staff Management (55%; up from 16%) as the commonest stressors.⁶ Several authors indicate that common, clinically related stressors, such as managing the anxious patient, have less emotional impact than pressures of running behind time, excessive workload, governmental interventions and staff management.^7,8,9 Using the MBI, Gorter et al surveyed 709 practising dentists, and found that males in the age group of 40 to 50 scored higher in Depersonalization and Emotional Exhaustion subgroups.⁹

Karasek proposed the Job Strain Model, which has been widely used in evaluating work-related stress in healthcare professionals.¹⁰ This model assesses both psychological job demands and level of job control, and the combination of high demands and low control has been shown to predict serious health consequences¹¹ and psychiatric morbidity.¹²

In a UK-based study, Denton et al¹³ added the use of an evaluation of Work Engagement,¹⁴ a different, but related, construct to Burnout, which they felt added to the insight of the impact of dental practice on the working lives of dentists. Their cross-sectional survey of 335 dentists found that 24.5% exhibited high levels in 2 of the 3 Burnout domains, with 8% scoring severe in all 3 categories. Emotional Exhaustion was higher in general dentists than those with higher qualifications; higher in solo practitioners than those working in groups. The greater the extent of working within the NHS, the greater was the increase in depersonalization and decrease in perceived personal accomplishment. Work engagement was significantly greater in those with postgraduate qualifications, however, the authors suggest that those who seek additional qualifications may exhibit more resourcefulness and be less liable to go on to develop Burnout.

Warr suggests that Burnout differs from Depression in that the former is job-related, while the latter is independent of context.¹⁵ Accordingly, the depressive person is likely to experience loss of emotional energy both at work and at home, while the Burnout patient generally has greater loss of energy at work.

The rise of social media

Since the turn of the millennium the internet has become the dominant medium for Dental Marketing, Self-Promotion and Group Discussion. Many of the studies of Burnout in health professionals were carried out before the rapid growth of social media. There is therefore little evidence of either positive or negative effects of social media in the prevention or, indeed, acceleration of Burnout in dentists or other health professionals. We are also faced by an increasing number of patients who are ‘Google knowledgeable’ about dentistry and this may have the potential to impact negatively on the Job Strain situation by producing increased and often unrealistic demands, with the dentist unable to control the relevance or accuracy of the information accessed by the patient. A Google search for ‘Smile Design’ yields over 35 million results, while ‘Periodontitis Treatment’ gives a little over 16 million.

It is the purpose of this paper to discuss Dental Burnout in the context of the Social Media Age. The possible positive and negative effects of social media; the contributing factors, early recognition and strategies to prevent or minimize the damaging effects of Burnout will be discussed. In addition to the well identified phenomenon of Dentist Burnout, it will be suggested that there is an additional condition – Patient Burnout; less well recognized but just as real and possibly a contributing factor to the condition in Dentists.

In order to introduce a contemporary dental perspective on the factors which can contribute to this problem in dentists, with permission, excerpts from the autobiographic text of one of the authors will be reproduced.¹⁶

‘There he is, the flash urbanite, in his early forties, driving down the long, sweeping bends in his newly acquired, very fast Audi saloon. A beautiful woman is by his side and the car journey from Glasgow out to the Loch Fyne Oyster Bar usually takes about an hour. They would have driven it in just thirty-five minutes had it not been for the conscientious traffic police just beyond the ‘Rest-and-be-Thankful’ pass. It's his third speeding ticket since he bought the car a few weeks ago and something tells him it might be time to slow down. But the something telling him this is not very loud and has to compete with all sorts of other voices, so consequently it goes unheard.

You might know the man. You'll certainly have seen him, or his female equivalent, relaxed, casually dressed (but not cheaply, heaven forbid), nice car, nice house, nice lifestyle (as the tabloids say) if you care to look. Nice life. Lucky, lucky b*****d.

Of course, all is not as it seems. Here's what you don't see: car by Audi Finance. Clothes courtesy of Amex. Interior furnishings by Visa. Mortgage by soul-sold-to-the-devil. And that's just the tip of the iceberg (or in his case perhaps, the lollo rosso). By the time he's thought about all the other debts, (which he tries so terribly hard not to do) the ones his business has built up to make it so impressive to onlookers, he realises he's not just poor, he's broke. And if he stops working for a second, it'll all fall to bits. And he's not unusual. All over Britain and the developed world, people who live as richly, comfortably, and twice as long as robber-barons, pay more to finance companies in interest than they do to themselves. And why? Just to surround themselves with luxury. Yes, but why? Because they can, because everyone else does and because, temporarily, it feels very, very good.’¹⁶

How can the intelligent healthcare professional get into this situation? As is clear above, the factors leading to this situation are complex and multifactorial. Lack of formal management training; keeping up with peers; unrealistic expectations; a sense of entitlement and, in some situations, a less recognized factor which may contribute, and even tip the balance towards, Dentist Burnout is the exposure to patients who are themselves undergoing a dentally induced Burnout experience. This condition of Patient Burnout will be discussed in a second article.¹⁷ For clarity, first, the various other factors which may induce Dentist Burnout will be discussed, then the influence of Patient Burnout will be the focus of attention.

Influences of social media – virtual group therapy

As has been noted above, Denton et al identified higher levels of Burnout in solo practitioners than those working in groups.¹³ For these individuals, access to professional Facebook groups, such as For Dentists, by Dentists or Mental Dental may provide the virtual group setting and collegiality needed to assist in reducing or preventing Burnout. Positive group discussion is dominant, with rapid responses to negative or insensitive comments. In the last few months, this has led to actual group meetings of stressed individuals with generally positive feedback.

In a medical setting, Girgis asked ‘Can social media help address physician burnout?

Based upon my experience, the answer could be yes. Beyond the ability to drive collaboration, social media and community have the indirect benefit of mitigating the stress and anxiety of running a medical practice. I've got support and a developed network to reach out to whenever I'm feeling overwhelmed.’¹⁸

There seems no reason why this positive use of the internet cannot be developed to assist those at risk. While the profession is well served by groups such as the Dentists Health Support Programme (originally called The Sick Dentists Scheme), its primary mandate is to help addicted and alcoholic dentists get into recovery. A similar structured programme offering dentists help in managing other manifestations of Burnout is much needed.

Influences of social media – please ‘like’ me

Every day many dozens of dentists post clinical cases ranging from single fillings to full mouth reconstructions; from mediocrity to excellence; from supervised neglect to gross overtreatment. The vast majority of what is shown features restorative treatment with little mention of cause-related therapy. Aesthetics, both dental and facial, dominate and there is a clear, if unstated, desire to be ‘liked’. More overtly, a recent online discussion on a dental site involved a dialogue on what was the best time of day to post a case to achieve over 500 ‘likes’. Opinions varied from first thing in the morning to just after siesta (not something often seen on an NHS day list).

Hakanen, Bakker and Demerouti, investigating the organizational and social psychological perspective on Burnout and work engagement, studied a group of 40 dentists.¹⁹ The dentists were split into two random groups in order to cross-validate the findings. Those with a strong need for social comparison were more susceptible to Burnout compared to those who had a low need for social comparison. This would suggest that those regularly posting their cases may largely come from a sub-set more susceptible to Burnout, and that less than expected praise or, as is often the case, criticism may accelerate this process.

The insecurities of this susceptible group may be further undermined by misguided, if well intentioned, efforts at humour, such as the following:

From another forum

‘What's your favourite technique to make other dentists feel inadequate? Here's a few of mine:

What are yours?'

A review of the stressors in this list leads us into the next potentially negative impact of social media.

Influences of social media – too much; too soon

With social media it is very easy for our colleagues to share their most recent luxury acquisitions (generally, a Bentley, Range Rover or Porsche). Certainly, more Rolex than Timex. They seldom discuss the years of extra training and experience which allowed them to pay for these ‘boy toys’, or indeed the extent of their overdrafts. Generally, the years of training and experience are inversely proportional to the size of overdrafts.

As Hakanen et al noted, those with a strong need for social comparison were more susceptible to Burnout compared to those who had a low need for social comparison.¹⁹ It may be that the blatant displays of ‘success’ are subconscious cries for positive recognition. They do, however, have the potential to cause major psychological damage to less experienced and possibly less talented colleagues who see them as role models, and want to be the next Dr X.

A recent Facebook comment sums up the situation very well…

‘It's brutal the GDC, the compliance the patient expectations and then you have to run a business it really is tough but the profession spray the image of fast cars and lots of cash nothing could be further from the truth the good guys sometimes have nothing left to give.’²⁰

The problem seems to be global. A colleague recently returned from giving a presentation in a Saudi dental school, noting that most of the male dental students talked endlessly of these luxury goods, which they expected almost as an entitlement, to be theirs soon after graduation. There was much less discussion on acquiring advanced dental skills in order to fulfil these dreams.

But dreams become possible sooner with the help of a friendly banker and the generous availability of bank loans, mortgages and credit cards. While banks seem to have learned much from the financial crisis of the late 2000s, they are still often prepared to make unsecured loans to ambitious young dentists who lack even basic business training, and who will often be influenced by dynamic Selling Coaches before developing skills in effective Delivery. Pressures for practice marketing to include every conceivable ‘popular’ advanced treatment from ‘Implants’ (usually implying completion in a few days), to ‘Invisible’ or almost ‘Instant Orthodontics’ and, of course, ‘metal free’ treatment; veneers and bleaching are the norm; many venture outside the mouth and, after a weekend or two, become ‘facial aesthetic practitioners’. All delivered in a studio, spa or even a gallery atmosphere. Sadly, these marketing efforts place little emphasis on ‘diagnosis’ and ‘treatment planning’ or on controlling the causes, rather than the effects, of common dental diseases and ageing.

With the possible exception of obstetrics and cosmetic surgery, medicine has largely matured to a point where GPs provide a differential diagnosis and referral for the most complex problems, manage simpler commoner illnesses and co-ordinate the patient's overall management. Few of us would agree to our GP doing an endoscopy, skin graft or bypass surgery after a weekend course on the technique. Yet a recent review of the internet shows an offer for ‘experienced’ dentists the opportunity of learning ‘sinus lift’ procedures in 7 hours for £1650. Since this fee included a ‘free’ surgical kit, it seems clear that this is considered enough training to start doing the procedures.

Let us consider another personal observation of one of the authors:

‘I had enough debt that even in my seven-figure business, I could barely afford to stay afloat. ……………. I didn't even know if my wife knew the full extent of my debt – I really didn't even know if I knew. It was a mess. I could still seem to be holding things together, my persona was more or less intact, but inside, I was a bit chaotic (my thesaurus informs me I should say, ‘completely f_____ up’. I was a full-time dentist and part-time art gallery owner, as well as a full-time small business manager and the pressure was affecting my health. I really didn't want to wait and see how long it would take before I cracked.’¹⁶

While the author's successful solution to his escalating problems was to face up to the situation, set more realistic professional and life goals which included selling his practice, and moving with his family to a much more low-key rural practice in New Zealand, many colleagues in similar situations are not so wise. The next section deals with factors which may precipitate Burnout and the possible compounding influence of contacts with the Burnout Patient.

Getting in out of our depth

It seems logical when learning to swim that we start at the shallow end and eventually, having gained confidence and experience, progress towards the deep end. At a presentation in Ireland, Dennis Tarnow, then Professor and Chairman of Periodontics and Implant Dentistry at NYU, showed a scan of a case treated by a young dentist in Manhattan, where multiple implants were placed using ‘guided’ and ‘flapless’ surgery, with more than half the implants either partly or completely out of bone. The patient was the CEO of a Fortune 500 company. To an audience of over 100, Professor Tarnow stated that, ‘….this dentist in now being sued for more than everyone in this room is worth.’

A combination of the aggressive marketing by dental manufacturers of equipment for advanced procedures and often unproven products; charismatic travelling lecturers who under-emphasize problems and complications and offer a simplistic approach to ‘planning’ complex multidisciplinary cases; a macho approach to treatment – ‘I can do anything’; and often a decision to take on too complex cases for financial reasons, can initiate a vicious chain of events (Table 1).

While every dentist should strive for continuous improvement and the ability to offer (and deliver) more advanced care, it is essential that this is done for the best of motives and with appropriate self-reflection on outcomes of this level of treatment. Sadly, there is a temptation to undertake complex treatments as a means of dealing with financial problems and, when all does not go to plan, Patient Burnout, and its associated challenges, can result. The inability to deal with problems and complications in such a patient adds to dentist stress and the vicious circle continues.

Several endodontists have told me that dentists, who referred molar endodontics up to the 2007/2008 financial crisis, then started doing these teeth themselves as their practices became quieter. Sadly, the endodontists are now re-treating many of these cases, and the authors are sure others are being replaced by implants or bridges.

Recent research by Derks et al examined a huge sample size of Swedes who had implants placed, with government funding.²¹ They found that implants placed, restored and/or maintained by general dentists had a significantly higher failure rate than those managed by specialists. To be honest it shouldn't really be a surprise. However, companies and individuals continue to offer relatively short training courses in all aspects of implant dentistry. When the CEO of a major implant company was asked some time ago if he felt it was better if 20 dentists placed 500 implants a year, or 500 dentists placed 20 implants a year, he was quite honest in his reply. ‘……for the patients it's better for 20 dentists to place 500 implants; from the company's point of view it is better if 500 place 20 since we sell 500 surgical kits not 20’. Financial interests and commercial forces can drive the vulnerable dentist to the deep end before he/she can survive there.

Lack of management training

By and large, faculty members in dental schools are well qualified in didactic and clinical dentistry but have little, if any, formal training in management. Some may even have ‘retreated’ to academia because of experiencing problems managing in private practice. Learning how to manage a practice is often left to the Vocational Training period, and to a principal who is often equally ill-equipped in formal management skills. It is clear from Gorter et al that, while clinical stressors tend to decline as the dentist gains experience, management issues such as, Practice Organization, Legal and Insurance matters and, particularly, Staff Management, increase in the first several years of practice.⁶ While every country is different, within the UK, well intentioned third parties, such as the GDC and CQC, acting in the patients' interests, may inadvertently add to the management stresses experienced by conscientious clinicians. To be successful, any small business needs to be based on the sound combination of a quality product or service; effective ethical marketing; a sound financial basis and effective operations management. It is fundamental that we are able to ‘deliver’ what we ‘sell’.

The constraints within the NHS, largely due to funding and staff shortages, as well as the disconnect between management and clinicians, have been described as causing Moral Distress.²² This is defined by Jameton as follows:²³

‘Moral distress arises when one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action’.

Morley's description of components of Moral Distress include anguish, fatigue, exhaustion, frustration, guilt, cynicism, a sense of isolation and loss of meaning.²² Though related to the nursing profession, these are alarmingly similar to the symptoms of Burnout in dentists discussed above.

Denial – unwillingness to accept problems or seek help

The old adage ‘when you are in a hole, stop digging!’ is often applicable. One of the authors was recently told of a young dentist who extracted the wrong premolar for orthodontic reasons. Instead of seeking help from either the orthodontist or a more experienced colleague, she re-implanted the premolar and took out the adjacent tooth. Few orthodontists ask for two premolars to be lost in the same quadrant, however, a combination of ego, denial and probably fear, led to making a bad (but likely manageable) situation much worse.

Too often blame is redirected to a third party (‘the lab got it wrong’) or even to the patient, rather than accepting responsibility, seeking help as needed, then managing the problem. While not everything can be expected to go seamlessly in complex treatment plans, patients start to question excuses, particularly when the same third party is repeatedly blamed. If the lab is blamed more than once, the discerning patient will wonder why you use that particular lab.

The authors have heard of dentists who gave up their efforts to ‘go private’ because of frustrations resulting from a failure to communicate fully to the patient possible additional costs, most commonly a tooth being prepared for a crown, which ends up requiring endodontics, or an implant which required a bone graft in conjunction with placement. In a follow-up article, the authors will stress the need for clear written communications with the patient and underselling and over-delivering on complex care.¹⁷ It is known that there is an average risk of 15–20% that a vital tooth prepared for a crown will need endodontics. Since averages do not apply to individual patients, neither does stating when proposing 10 crowns ‘…you should be prepared for up to 4 teeth needing root canal treatment; the potential costs will be £ xxx per tooth’. Few patients decline 10 crowns because of the possible endodontic fees. If the patient needs fewer than 4 root treatments, they are delighted with the lower fee and dental expertise. If they need more than 4 root treatments, perhaps diagnostic or manual skills should be called upon.

Many national dental associations offer help for dentists with stress-related and other health issues. As discussed above, in the UK the Dentist Health Support Programme and Trust carries out important work. Early identification of potential Burnout is essential and, to this end, the Dutch Dental Association introduced a ‘Stress and Burnout Thermometer’ allowing dentists to assess their current state anonymously; 12% of all members used this within 5 months of its introduction and response was overwhelmingly positive.⁶

Inability to cope with problems with potential Burnout patients

The next article will advise on identifying potential Burnout patients and preventing or managing their challenges.¹⁷ While every patient is different, many of these strategies are applicable to the majority of such patients and there is a common first step which is often underused.

Saying ‘I am really sorry you are having these problems’ is not an admission of guilt, merely an expression of empathy, but can be enough to defuse a difficult confrontation and allow critical appraisal of the situation. As the stress level and blood pressure reduces, possible strategies to manage the patient can be considered; help sought as required and, hopefully, Burnout of both patient and dentist averted. It is essential, when such a situation has been defused, to follow up promptly with proposed solutions.

Substance abuse and dependency

This is a too common response to potential Burnout. While it is beyond our expertise and the scope of this article to address these major problems in any detail, it is clear that this is an ineffective form of denial. While it may offer temporary relief from increasing stresses, it can only result in a downward spiral as reliability and quality of care deteriorates, relationships break down and patient complaints increase.

Attraction of current dental fads and fashion

Despite a growing emphasis on the use of evidence-based dentistry, many dentists are drawn towards the ‘latest’ techniques. Often the attraction of being the first in your area to offer these peripheral services is driven by potential financial gain, and evidence takes a back seat to promised profits. It can be attractive to a dentist, hurtling towards self-inflicted Burnout, to see these niche products as a potential salvation in a deteriorating situation. In the 1880s, Osler advised ‘…Never be the first to take up a new technique, or the last to discard an old one’.2⁴ It is still sage advice today.

Those who see Botox and Fillers; Smile Design; 6 month Smiles; Laser Dentistry; Teeth in a Day; metal-free dentistry and so on, as a salvation to their growing problems, at the expense of established diagnostic and care planning principles, are more likely to worsen than to solve these problems. Too often we see patients having ‘finished’ so called cosmetic treatment, with calculus on their roots, bleeding gums and blocked embrasures and overhanging margins which only complicate the situation and ultimately predispose to patient Burnout.

Though it is fashionable to substitute Client or Customer for the traditional word Patient we should not lose site of the common Latin derivation of Patient, the Adjective and Noun.

Patient the Adjective is defined as ‘……able to accept or tolerate delays, problems, or suffering without becoming annoyed or anxious’.

While the Noun is defined as ‘……a person receiving or registered to receive medical treatment’.

In Latin the participle form patientem, for one who is suffering, has taken on the extra sense of somebody who suffers his/her afflictions with calmness and composure, hence longsuffering or forbearing, all ideas intimately tied up with our word patience.

‘Treating Clients’ must be avoided and time taken to ‘Care for Patients’. To do otherwise is to denigrate our profession. To minimize potential problems, it is wise for both the dentist and the patient to be patient. Unrealistic patient timeframes, or dentist promises should be avoided. Faster is not generally better, otherwise we would only eat out at McDonalds. Equally, younger dentists who fall into the ‘too much, too soon’ category should be prepared to be patient in developing advanced skills. It takes 20 years to gain 20 years of experience; improvement is often based on reflecting on our mistakes.

Pressures from corporates

In a previous article the authors commented on the likely life cycle of dental corporates.²⁵ Although Boots and Optical Express have entered then left the corporate dental arena, other corporate bodies continue to offer dental services. These appear to operate on a sounder business plan than those who have departed, however, dentists who feel that this form of practice will relieve their stresses and non-clinical responsibilities must realize that they may be sacrificing full clinical freedom, and be more subject to ‘Targets’ and ‘KPIs’ than those in independent practice. On occasion, clinicians may find themselves providing ‘Specials’, more in tune with supermarket marketing than healthcare provision. Where there is a disharmony between personal and corporate goals, or between treatment philosophies, there is the potential for growing frustration, and the ‘Job Strain’ category of high demands and low control. In susceptible practitioners, this can contribute to their Burnout.

Loss of control

The combination of some, or all, of the factors outlined above amounts to a feeling of Loss of Control. This can be manifest in financial, professional and social forms and generally incorporates a component of all of these. A perceived need to project a successful image, both professionally and socially, can lead to financial difficulties. By all means go to a 5-star hotel if you can afford it, but why post it online? Save up before you buy the Mercedes; your parents did. Growing debt may prompt the treatment of more complex, potentially remunerative cases beyond the dentist's expertise. As problems develop with these cases, stresses may detrimentally influence home life. ‘Getting out’ by joining a corporate may appear to be an attractive solution but the additional loss of autonomy may actually worsen the situation. This downward spiral will end in Burnout unless arrested in time.

Jerome, clearly with the considerable support of his wife, was fortunate to have a Damascene moment on the road to Loch Fyne and to slow down, both literally and metaphorically.¹⁶ By overcoming the natural tendency to deny the problem, he was able to face up to the situation and willing to make the changes, appropriate to his family's needs, to take a different path.

Conclusions

This article attempts to update perspectives on Dentist Burnout with the rapid growth in social media. Patient Burnout has been briefly discussed, as well as its potential relationship to Dental Burnout. This aspect is expanded on in the later article.²³ These observations are experience-based rather than evidence-based and should be taken as such. Like all ‘Syndromes’ not all signs and symptoms are found in every case. It seems certain, however, that modern dentistry, with increased treatment choices, a shorter half-life of knowledge, higher patient expectations and increased regulation and litigation will continue to be a stressful profession. Like any affliction, Burnout, both in dentists and patients, is at best prevented, or at worst treated as early as possible. We have attempted to describe some of the warning signs.

In the 21st Century, dental schools surely have a moral obligation to teach at least the basics of running a small business. For many of us, our business education consisted of a slide showing an NHS claim form, and a discussion on GDC regulations. Today, how to ‘Cut and Paste a CV’ appears to have been added. The huge investment involved in training young dentists can only be fully effective if this training includes the business and life skills necessary to maximize the possibility of a long, happy and productive career.

Social media has had an unprecedented influence on everyone's life in the past 15 years. Though potentially a force for good in terms of reducing the isolation of individual dentists, it also has the potential for great harm for those pre-disposed to Burnout by highlighting their sense of reduced personal accomplishment. Virtual reality is certainly ‘virtual’ but is often not ‘reality’. The profession and its regulators should give appropriate consideration to these changing stressors in 21st Century dental practice.

If you recognize yourself in some of the scenarios outlined above, take stock and consider the direction in which you are heading. If you do not recognize yourself, reflect on whither you are fortunate or merely in denial.