Crash & burn
Scottish Dental continues its exploration of the growing stress, anxiety and depression crisis that is afflicting the dental profession and talks to some of those working to counsel, help and relieve those suffering
It is now well recognised that rates of burnout within the dental profession are significant. Studies from around the world quote rates of 15-84 per cent depending on the dimension of burnout studied1.
The prevalence of burnout varies according to gender, age, career stage and practice setting. Burnout symptoms correlate with the extent of NHS or public work undertaken and to a lesser extent to the number of hours worked or patients seen. Younger dentists appear to be most vulnerable. While general dentists and oral surgeons appear to have the highest rates of burnout, orthodontists appear to have lower rates of burnout 2,3.
The impact this has on the wellbeing of dentists, patient safety and patient satisfaction is now a recognised challenge.
Dentists should resist the deeply ingrained need to work even if unfit, known as 'presenteeism'. They should be encouraged to take time off without fear or guilt
Dr Suzy Jordache
Determination and dedication to meet the demand and fulfil personal and patient expectations can lead dentists into a very unhealthy relationship with work that spills over into their family life and can have an effect on their health. There are also clear dentolegal consequences.
As Professor David Peters, Director of the Centre for Resilience in London, states: “Long-term drowning in high levels of adrenaline and cortisol eventually makes you ill. But before that, it makes you stupid and unfriendly.”4
Litigation and complaints are often seen to arise against the background of a burnt-out, unhealthy clinician. Deficits in cognitive control, working memory, reasoning, skills in problem-solving, planning and execution lead to unsafe clinical decision-making with impaired performance. These can lead to a decline in the dentist-patient connection and the deterioration of professional relationships 5,6.
What is burnout?
Burnout is an occupational hazard that occurs frequently among professionals who do ‘people work’ of some kind. According to Mindtools.com, burnout occurs when “passionate, committed people become deeply disillusioned with a job or career from which they have previously derived much of their identity and meaning. It comes as the things that inspire passion and enthusiasm are stripped away, and tedious or unpleasant things crowd in”.
The widely recognised Maslach Burnout Inventory (MBI)7 proposes three domains that make up burnout:
- emotional exhaustion
- depersonalisation – a cynical attitude with distancing behaviours
- low sense of personal accomplishment.
Burnout reflects an uneasy relationship between people and their work. Avoiding burnout requires a commitment to build or sustain the opposite of burnout – engagement at work. Psychology professors Christina Maslach and Michael Leiter propose that engagement and joy at work can be determined from the following six areas of work 8:
- workload (too much work not enough resources)
- control (micromanagement, lack of influence, accountability without power)
- reward (not enough pay, acknowledgment or satisfaction)
- community (isolation, conflict, disrespect)
- fairness (discrimination, favouritism)
- values (ethical conflicts, meaningless tasks).
What can be done to avoid or reverse burnout?
The first step in avoiding burnout is to carefully scrutinise your relationship with your current workplace and ensure that potential difficulties in each of the six key areas of work are minimised or resolved. If this is not possible, a change of environment or workplace can reverse burnout completely.
It is perhaps astonishing that so many dentists continue to practise in the full knowledge that their workplace generates risk of burnout for them in more than one of the key areas. It is equally astonishing that despite evidence that complaints, productivity and staff turnover are significantly affected by burnout, employers consistently fail to address the problems.
To avoid or reverse burnout and build engagement requires careful attention to develop good individual coping strategies in the workplace. Organisational policies and procedures must ensure these coping strategies are respected and enforced. As a starting point, it is important for dentists to focus on physical and emotional wellbeing and to ensure that their sense of calling is not eroded. This can require a profound shift in mindset and behaviour for many dentists.
Physical wellbeing: Developing rituals and routines that promote regular healthy eating, hydration and sleep underpins all other more sophisticated strategies.
Unfortunately, many dentists find that their workplace culture requires them to have considerable courage to say “no” to skipping breaks and taking on extra work. Prioritising personal wellbeing can be a significant challenge for many. Often dentists give much of their energy to their work and arrive home exhausted and unable to enjoy or participate fully in time with family and friends; they fail to exercise or eat healthy food and struggle to relax into restorative sleep.
Managing their energy rather than their time is a key concept to ensure safe performance across a practising lifetime9. Prioritising and diarising activities outside of work to support high performance at work can help.
Dentists should resist the deeply ingrained need to work even if unfit, also known as ‘presenteeism’. They should be encouraged to take time off work without fear or guilt if they think that they are infectious or feel unsafe to provide care.
Proactive employers will have policies and procedures in place to insist on this and reduce these
under-recognised risks to patient safety and satisfaction and dentist wellbeing.
Emotional wellbeing: Coping with the stress of working with suffering, anxious or demanding patients day after day requires attention to emotional wellbeing to avoid secondary traumatic stress disorder or compassion fatigue. Mindfulness, journaling, and peer support groups10 are evidence-based techniques that promote self-awareness and resilience. There is evidence that a growing number of social media support forums can help significantly11.
Interestingly, some research and opinion suggest that introverts and extroverts recover energy very differently. In the book Introvert Power, psychologist Laurie Helgoe suggests that introverts recover energy best when reflecting alone, and extroverts recover energy best when interacting with others.
Sense of calling: A sense of mission and purpose can also build resilience and maintain engagement. Remembering why an individual chose dentistry and celebrating achievements that align with these values can be a powerful way to bounce back in an environment that constantly challenges and surprises. Employers can support this by collecting evidence and stories of good practice as well as rewarding, thanking and celebrating their employees’ success.
It is unsustainable for a dentist to continue working in an environment that constantly introduces ‘moral distress’. When such practice is at odds with their personal values, steps should be taken to address the mismatch, or they should seek different employment.
Evidence across healthcare settings strongly suggests that individuals cannot build or maintain resilience in isolation12. It is crucial every employer understands this and works carefully with individual dentists so that they are less likely to experience burnout.
In a dental partnership where they have autonomy over their workplace, dentists will have to regulate their energy needs to ensure safe practice and avoid burnout. This level of self-discipline with the potential impact on earnings is required to sustain long-term health and career satisfaction.
Whether you are an employer or an employee, avoiding burnout will require thought and action.
As Maslach and Leiter wrote before: “When burnout is counteracted by engagement, exhaustion is replaced by enthusiasm, bitterness by compassion and anxiety with efficacy.”13
Please visit Dental Protection education site
Dr Suzy Jordache is Senior Medical Educator at the Medical Protection Society
- Singh et al, Systematic review: Factors contributing to burnout in dentistry, Occupational Medicine 2016;66:27–31
- Zini et al, Burnout Level among General and Specialist Dentists: A Global Manpower Concern Occup Med Health Aff 2013,
- BDA Research Paper: Larbie et al, The Mental Health and Well-being of UK Dentists: A Qualitative Study, Aug (2017)
- David Peters Resillience Podcast, available here.
- Chipchase et al, A study to explore if dentists’ anxiety affects their clinical decision-making, Br Dent J 2017 Feb 24;222(4):277-290 (2017)
- Basson, Management and Prevention of Burnout in the Dental Practitioner, Basson, Dentistry 3:2 (2012)
- Maslach et al, The Maslach Burnout Inventory (3rd ed). Consulting Psychologists Press (1996 )
- Maslach and Leiter, Reversing Burnout. How to rekindle your passion for your work, Stanford Social Innovation Review, 2005.
- Loehr and Schwartz, The Power of Full Engagement, Free Press Paperbacks 2005
- Eaton et al, The impact of continuing professional development in dentistry: a literature review, The Faculty of general Dental Practice for The General Dental Council (2011)
- Bain & Jerome, Dental Burnout – Is Social Media a Help or Hindrance? Occupational Health Dent Update 44:937-946 (2017)
- Panagioti M, Controlled Interventions to Reduce Burnout in Physicians, A Systematic Review and Meta-analysis JAMA Internal Medicine Dec (2016)
- Maslach and Leiter, Reversing Burnout. How to rekindle your passion for your work, Stanford Social Innovation Review, 2005