Christine A. Botchway, BDS, LDSRCS (Eng), DDPHRCS (Eng), M.Sc. (Pub Health)
© J Can Dent Assoc 2000; 66:31-2
My father once said that the journey of dentistry was not for the weak in spirit. Had I bothered to ask what he meant, he would gladly have elaborated. In the days of my youth, my fathers passion and allegiance to his profession captured my attention and stimulated my affinity for the profession that emulated a spirit of nobility, excellence and invaluable contribution to humanity.
Throughout my years of apprenticeship, the potential negative cumulative effects of our profession on the human spirit did not appear a relevant part of our curriculum.
My first job was a whirlpool of stress-related undercurrents that I had seldom experienced within the controlled environment of dental school. Time became constricted and the inbred need to uphold the pure standards of my training in an imperfect environment was activated. In striving to be all the persons my profession required of me, at the standard that I believe our profession merits, I often experienced the sensation of having been thrown headfirst into raging whitewater with a leaking raft, a paddle and an overall knowledge of the breaststroke. I had to proceed up the sharpest learning curve in the shortest time to try to master the additional skills of communicator, businesswoman, health promoter, counsellor and vigilant warrior against the powers that would corrupt me. But perhaps the hardest skill of all was mastering the ancient order of silence and passivity as the shackles of stress began to attempt to close around my wrists.
I laboured long hours with an enthusiasm that slowly diminished as I found myself having to work in less than perfect conditions, working to a rigid schedule and enduring the wrath of some of the patients if I ran late (and I often did). The work could sometimes appear repetitive and even mundane. Exhausted at the end of each day, I held sacred my day off.
For the first time, I experienced the negative stereotypical perceptions of the public to my profession. I was often greeted with the words, I hate dentists. Oh, youre the dentist? I thought you were the nurse. You look too young to be a dentist ...
My patients expected me to be all-knowing, to cause them some amount of pain, never to include them in decision- making and to have a hide of indifference to any negative attitudes and comments. I did not fit their stereotype in any way. Sometimes this worked for me, and sometimes against. It certainly bestowed favour on me as I dealt with fearful patients, with whom I gained much experience. Despite this, dealing with fear effectively but quickly sometimes caused my own stress levels to rise. Similarly stressful were my dealings with some disabled patients, when diminished communication and constant interruption to procedures were common. After receiving two consecutive needlestick injuries I became stressfully aware of the real dangers I faced each time I picked up a needle or mixed a potentially toxic substance. Furthermore, the quality of my work depended greatly on the support of my assistant and the forward planning of my receptionist. Some of these individuals were marvellous, but others were less dedicated than I might have desired, and just the odd miscommunications could complicate things further still. I had to confess I was stressed up to my eyeballs.
Finally I presented my observations to a senior colleague. He implied that my youth and inexperience were the culprits. That was that. But my curiosity was tweaked. I began to take note of all the stressors around me and to try to find ways to diminish their effect.
My colleagues vaguely described similar experiences. But as we became initiated apprentices in the confines of our trade, we convinced ourselves that the stress levels under which we habitually resided were probably normal and even necessary to reach our ultimate goals, all of which differed vastly. But still in the isolated confines of my office I sat in a dilemma. Every practice I visited had its own stressors, yet many trudged along as though this were a normal healthy existence. Hesitantly, I decided that, to me, these stresses (though an inevitable part of work) could be detrimental when minimized. I began to take greater interest.
Included in my investigations were Simon, the often-suicidal alcoholic; Peter, who drove himself to exhaustion; James, who every five months had a nervous breakdown and burst into tears at the office, dyed his hair or pierced his ears and then went off on an expensive holiday to Tenerife; and Paul and Trevor, who had both divorced their wives and now lived with their assistant and nanny, respectively.
As I pooled the anecdotal data, I was fascinated to discover an uncanny similarity in these dentists core personalities. All appeared to exhibit type A-like personalities, all were good dentists, all were in constant stress, all appeared to need constant praise, all were compulsive workers and perfectionists, all had troubled marriages, all needed to hold complete control, and all strenuously denied difficulties in coping with stress.
What baffled me was why they chose to ignore all the stress factors and create more by their compulsive striving for self- perfection. It seemed that the very nature of some personalities and the individuals consequent needs compelled these people to press on despite emotional and physical burnout - toward an unattainable standard of excellence, almost as if to prove their self-worth and/or to maintain control. A result of this addictive behaviour was a highly stressful environment for themselves and their staff. What was worse was that they neither acknowledged nor dealt with the stress they were under. And they were not the only ones susceptible. Those of us who acknowledged stress consciously or unconsciously battled it daily through trial and error and without much of a support system. I was fortunate to have the mentorship and support of the Defence Union of Scotland at the time and the anchoring strength of a deep Christian faith.
Finally, I understood what my father had meant. How easy it was to exist in denial of the stresses how much harder to admit that an age-old occupational hazard was eroding the very fibre of our profession.
Dentistry has been identified as a highly stressful profession.1 Working in close contact with clients can cause emotional exhaustion, depersonalization and reduced personal accomplish ments. In addition, the working environment and personal characteristics of the dentist play a role in burnout.2
Interestingly, most practitioners deny or trivialize suggestions that they suffer burnout, perhaps in an attempt to disguise personal vulnerability and uphold the misconception that the dentist is always in control (although research suggests that an increasing number of dentists are showing symptoms of psychological disturbances).3 Indeed, research suggests that of all health care professionals, dentists and practitioners are most prone to physical and mental ill health.4 Studies have identified that stress is ingrained in dental practices, although it is understood that different people react differently to stress.5
Comprehension of character may be key to understanding response to stress. Research suggests that the characteristics of many dentists may have a link with inadequate nurturing in childhood, which leaves the adult ultimately lacking in self- esteem and yearning for recognition.3 The type A personality is cited as common in dental professionals. This behaviour is learned early in childhood and is linked with reward for tasks successfully completed. It is also linked with coronary heart disease.6
It is not unreasonable to infer that for a successful practice, control of stress is mandatory.7 But it would appear that dentists who compel themselves to work in an obsessive manner begin to see little other than the walls of their surgeries. They feel guilty about taking holidays and worry about decreased productivity. Hence, much-needed leisure is denied8 and more stress created.
It is my concern that we as a profession downplay and sometimes even deny the existence of the stress levels under which we operate. Failing to acknowledge, identify and deal with this chronic erosive force can drain us of vitality, inspiration, sense of orientation and rationality, making us slaves to stress.
Is our stress born of our pure desire to implement idealistic ideals into an impure system a by-product of the type A- related obsessive need to maintain control or simply an element of human materialism? There are several well-established remedies to relieve stress: time management, teamwork, optimum cooperative patient pool, good practice management, good treatment planning, continuing education, frequent holidays, good patientstaff communication, positive self-image, other interests, regaining our focus. But I believe that relief begins with the acknowledgment that we need to deal with stress daily and continually, with a coping mechanism that does not create more stress.
We need to capitalize on our strengths and interests. We need to release the controls and build on strengths, interests, teamwork, respect, communication and delegation. And we need to admit when we are stressed.
Once we have found that the journey toward our goal may be detrimental to our soul, we must stop, acknowledge, plan and change the route lest the severity of the journey wilts our spirit such that, by the time we arrive at the destination, our soul is lost.
Like my father said, the journey of dentistry is not for the weak in spirit.
Dr. Botchway is a clinical assistant professor, oral diagnosis, oral health sciences, faculty of medicine, University of Alberta.
The views expressed are those of the author and do not necessarily reflect the opinion or official policies of the Canadian Dental Association.
References1. Freeman R, Main JR, Burke FJ. Occupational stress and dentistry: theory and practice. Part II. Assessment and control. Br Dent J 1995; 178:218-22.
2. Osborne D, Croucher R. Levels of burnout in general dental practitioners in the south-east of England. Br Dent J 1994; 177:372-7.
3. Joffe H. Dentistry on the couch. Aust Dent J 1996; 41:206-10.
4. Freeman R, Main JR, Burke FJ. Occupational stress and dentistry: theory and practice. Part I. Recognition. Br Dent J 1995; 178:214-7.
5. Bourassa M, Baylard JF. Stress situation in dental practice. J Can Dent Assoc 1994; 60:65-7, 70-1.
6. Christen AG, McDonald JL Jr. Management of stress in the dental practitioner. Den Clin North Am 1986; 30(4 Suppl):S1-S146.
7. Hillman M. Stress and dentistry. Better practice through control. NY State Dent J 1995; 61:50- 2.
8. Manji I. Time out. J Can Dent Assoc 1994; 60:667-8.