Patient and Dentist Burn-Out – a two way relationship

Crawford Bain and Lloyd Jerome

Part 2 – Dentist Burn-Out

Introduction

In the previous article we have defined Burnout and suggested that, in addition to the well
identified phenomenon of Dentist Burnout, there is an additional condition – Patient
Burnout; less well recognised but just as real and possibly a contributing factor to the
condition in Dentists.(1)

In order to introduce a contemporary dental perspective on the factors which can

contribute to this problem in dentists we reproduce, with permission, excerpts from the
autobiographic text of one of the authors (2).

“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 bastard.

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.” (2)

How can the intelligent healthcare professional get into this situation? As is clear above,
the factors leading this situation are complex and multifactorial. Keeping up with peers;
unrealistic expectations; a sense of entitlement and in some situations as discussed in our
first article a less recognised 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 (1). For completeness we will first discuss the various
other factors which may induce burnout, then focus on the influence of patient burnout.

Too much too soon

With the rapid expansion of social media it is very easy for our colleagues to share their
most recent acquisitions, (generally a Bentley, Aston Martin 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.

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 treatments 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. 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.

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 coordinate 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 review of the internet today
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. I 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.” (2).

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 Burn Out and the possible compounding influence of contacts with the
Burnt-Out 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, Prof. 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 unproven products; charismatic travelling lecturers who under-
emphasise 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 taking on too complex cases for financial reasons can initiate a
vicious chain of events. (fig 1).

• Make a big investment in new practice or equipment or technique

• Over-sell treatment to recoup investment

• Take on cases beyond skill level

• Encounter problems but go into denial (Cognitive Dissonance)

• Increasing patient complaints

• Buy a Ferrari/Yacht/Cocaine (to “feel” better)

• Spiralling debts and pressures.

• Cut corners with treatment to increase cash flow.

• Increasing intolerance to patient complaints

• Letter from GDC

• Burnout

Figure 1. The vicious chain of events leading to burnout

While every dentist should strive for continuous improvement and the ability to offer (and
deliver) more advanced care, it is essential that this done for the best of motives and with
appropriate self-reflection on outcomes of this level of treatment. Sadly these 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 retreating many of these cases,
and I am sure others are being replaced by implants or bridges.

Recent research by Derks et al (3) examined a huge sample size of Swedes who had
implants placed, with government funding. They found that implants placed, restored
and/or maintained by general dentists had a significantly higher failure rate than those
managed by specialists. If we are honest we really shouldn’t be surprised. However
companies and individually continue to offer relatively short training courses in all aspects
of implant dentistry. When I asked the CEO of a major implant company 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 they can survive there.

Denial – unwillingness to accept problems or seek help

The old adage “when you are in a hole, stop digging!” is often applicable. I 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 2
premolars to be lost on 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 accept responsibility and get on with 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.

We have heard of dentists who gave up their efforts to “go private” because of
frustrations resulting from a failure to fully communicate 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 the first article of this series (2) we stressed the need for clear written
communications with the patient and underselling and over-delivering on complex care.
We know there is an average risk on 15 to 20% that a vital tooth prepared for a crown will
need endodontics. Since averages do not apply to individual patients, stating when
proposing 10 crowns that “…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 less than 4 root treatments
they are delighted with the lower fee and your expertise. If they need more than 4 root
treatments perhaps you should reflect on your diagnostic or manual skills.

Inability to cope with problems with potential Burnout Patients

Our first article advised on identifying potential Burnout patients and preventing or
managing their challenges. 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.” 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
that 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 their afflictions with calmness and composure, hence
longsuffering or forbearing, all ideas intimately tied up with our word patience.

We must avoid Treating Clients and take time to Care for Patients. To do otherwise is to
denigrate our profession. To minimise 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.

Pressures from Corporates

In a previous article I commented on the likely life cycle of dental corporates (4). 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 realise that they
may be sacrificing full clinical freedom and be more subject to Targets and KPIs than those
in independent practice. Where there is a disharmony between personal and corporate
goals, or between treatment philosophies the potential for growing frustration may, in
susceptible practitioners 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
Gleneagles if you can afford it, but why put it on Facebook? 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 (2), clearly with the considerable support of his wife, was fortunate to have a
Damascene moment on the road to Loch Fyne and to both literally and metaphorically
slow down. 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

These articles have attempted to highlight both Patient and Dentist Burnout as well as
their potential relationship. 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 and higher patient expectations will
continue to be a stressful profession. Like any affliction, burnout, both in dentists and
patients is 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 (in my day an EC17), and a discussion on GDC regulations.
Today we appear to have added how to Cut and Paste a CV. The huge investment involved
in training young dentists can only be fully effective if this training includes the business
and life skills necessary to maximise the possibility of a long, happy and productive career.

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

1. Bain CA and Jerome L. Patient and Dentist Burn-Out – a two way relationship; Part
1 – Patient Burn-Out Dental Update 2017.

2. Jerome L, Cricket By Candlelight. Kindle Edition, 2012

3. Derks J, Hakansson J, Wennstrom JL, Tomasi C, Larsson M, € Berglundh T.

Effectiveness of implant therapy analyzed in a Swedish population: early and late
implant loss. J Dent Res 2015: 94(3 Suppl.): 44S–51S.

4. Bain CA. Corporate Dentistry; a 2020 Vision. Dent Update, 2000: May;27(4):163-4