PROFESSIONAL CENTER 

Beat burnout before it beats you

With a few simple strategies, you can learn to stop worrying and love dentistry again.

By Daniel McCann

Even back in dental school Dr. Don Nelson* had an inkling that his chosen field might, in fact, be far afield from what he truly enjoyed. Still, he never imagined his future unfolding the way it did.

During his dental school days in the 1950s, the studious and personable Nelson envisioned a professional life of fulfillment, security and growth. He kept his vague, occasional bouts of uneasiness safely tucked away.

Then came graduation, opening his own office and, like a missed exit on the expressway, the growing certainty that he was headed in the wrong direction.

Of his first year in practice, he recalls, “I felt trapped.” Those earlier, hazy misgivings now came to the fore, defined and dominant.  “Dentistry obviously requires an enormous amount of hand skill, and that had never been a strength of mine. I was always able to easily pass written tests and talk dentistry, but when you actually have to build the bird cage, well, that’s a different challenge.”

Quitting wasn’t an option. “I kept telling myself ‘I can learn how to do this.’ I was a married man with responsibilities and felt that I had to make the best of it, had to see it through somehow. The result: “I was stressed; I did not enjoy the practice of dentistry; every time you’re doing something you don’t enjoy you’re going to feel a bit stressed.” In time, the growing, unaddressed stress led to the beginnings of depression.

How did I get here?

During his second year in practice, Nelson made a change. He took on an associate to share some of the duties. And during the next two decades he would continue to add dentists to his staff, seven in all, until he served largely as administrator of his successful group practice.

His turmoil eased somewhat, Nelson immersed himself in stress literature to better understand the strains that had so perplexed him and helped to sidetrack his career as a wet-finger dentist. He became an expert on the topic and, in the 1980s, took to the lecture circuit full time to help other dentists deal with their stresses in order to avoid burnout. In his talks to practitioners, Nelson emphasized that for many stressed dentists, troubles start with a mindset steeped in contradiction. “Dentistry,” he says, “is an imperfect science practiced on imperfect people by imperfect dentists. But practitioners go into it presuming perfection, which is unattainable. Now that’s all absurd, but that is the way it is.”

Pursuing unrealistic goals can lead to stress—and worse. “Burnout is just accumulated stress,” says Nelson, “it’s more and more and more stress until you finally say, ‘No, I can’t handle this anymore.’”  Thus, heading off burnout  begins with managing stress, which starts with realistic appraisals of what’s within one’s capabilities and recognizing when a situation is beginning to cause strain.

Nelson’s career turnaround started with the acknowledgement that, for him, practicing dentistry was not satisfying. But what that dissatisfaction led to—researching stress and helping his peers deal with their own job-related strains—he found extremely rewarding. “I enjoyed it all very much,” he says today.

 According to Debra Klamen, M.D., a psychiatrist at Southern Illinois University medical school who conducts stress workshops for health-care workers, signs of stress fall into three categories: body symptoms—headache, gastrointestinal problems, fatigue; mind symptoms—excessive alcohol or drug use, forgetfulness, loss of concentration; and feeling symptoms—irritability, depression.

When dental consultants, psychologists, educators and others discuss managing stress in the dental office, their conversation turns to the three key players: patients, staff and dentists.

Ron Frey, Ph.D., a psychologist in Ottawa who counsels dentists, says practitioners are under unique pressures from the start. For one, they’re operating a business but have had very little training to do so.

 “Not many dental schools spend much time teaching future dentists how to run their practices, which involves everything from accounting to hiring and retaining employees,” says Frey. Then there are the challenges of dealing with insurance companies and keeping up with increasing government regulations.

Inherent contradictions

Moreover, these responsibilities are in head-to-head competition with what dentists went to school for in the first place: to treat patients and improve their dental skills. And that clinical emphasis, continues Frey, brings up another stressor. “Dentists as a group tend to be slightly more perfectionist than other individuals,” he says.

 Yet treating dental patients rarely unfolds with the predictability and precision of, say, solving a mathematical equation. “There are occasions when dentists have to make judgment calls,” says Frey, “where you have to develop an intervention or plan that might be slightly unorthodox. And that can be all the more frustrating when you have to explain it to an insurance company or the patient.”

In fact, for Dr. Barry  McArdle of Portsmouth, N.H.,  the biggest stressor in dentistry is having to deal with insurers. McArdle’s office participates in only one insurance plan, but still processes claims for patients signed on with other insurers.

 Sometimes, says McArdle, the insurers’ explanations of benefits to patients will raise questions about his treatments. “Those explanations will make me look like I’m overcharging the patients or doing procedures that aren’t necessary,” says McArdle, “and that can breed patients’ mistrust.”

In order to counter such perceptions and maintain credibility among his patients, McArdle emphasizes communication. “We always explain everything to patients,” he says. “We take nothing for granted in terms of what they might understand. So from that standpoint we’re very detailed.”

While the first step in dealing with stress is to recognize the problem, Nelson points out that can be challenging. “It’s not easy because we are trained in our society not to be introspective, not to pay too much attention to what might be happening with us,” he says.

During the past 15 years, Dr. Edward Grace has made a point of addressing such issues as self-awareness in his Introduction to Behavioral Dentistry course (which includes stress management) at the University of Maryland dental school.

“One of the first things we ask of students is to be introspective,” he says. “We give them personality tests, which they don’t have to share with anyone, just so they can get to know themselves.”  

Taking the time to step back and acknowledge a stressful encounter or experience—Did it make you nervous? Irritated?  Upset your stomach? Make it difficult to concentrate—is key to learning how to deal with it when it recurs. “Once students identify their own stressors and how they respond to them, they can build coping mechanisms to better deal with them,” Grace says. “But the first step is identification. Sometimes people tend to not look at a stressful situation; they tend to put it away and think they’ll get to it another day.”

Implementing strategies

Coping involves implementing strategies. “If you don’t like to do full dentures,” says Nelson, “stop doing them. Or take some courses and learn a technique that works better for you.”

Essentially, says Nelson, there are two ways to cope with stress: eliminate the irritant from your life or find a way to minimize its effect. In the case of a dentist stressed by the competing responsibilities of work and family, minimizing stress might mean spending fewer hours at the office.

As for the dentist overwhelmed by the business aspects of dentistry or who feels awkward talking at length with patients, it might call for delegating further responsibilities to dental staff and finding someone with strong communication skills.

Delegation, though, calls for careful planning, says dental consultant Linda Drevenstedt, president Drevenstedt Consulting, Suwanee, Ga. “One of the huge stressors for many of my clients is that they’re solo practitioners, so they develop a Superdoc Syndrome, thinking that they’re the only ones who can do payroll, or deal with government regulations and so forth. And when they have that mindset, they create a lot of stress for themselves and develop resentment toward their team since they feel so burdened by all they have to do.”

The solution is to involve staffers, which means not only training them but making them accountable, says Drevenstedt. It’s important, too, that dentists exercise restraint when they see a worker’s error.

 “One key to reducing stress in the dental office is how dentists handle the mistakes employees make,” says clinical psychologist Joseph Mancusi, Ph.D., president of the Center for Organizational Excellence, Sterling, Va., and a frequent lecturer to dentists on stress.

“Ranting is not a good way to handle them,” he continues. “Ignoring is not a good way either; but allowing the mistakes and then having a discussion of how to keep them from happening again is the best solution. Another thing some dentists overlook is giving employees encouragement, pats on the back for a job well done. That’s the type of thing you often see salespeople do, but not dentists. It’s not often part of their personality style. But if they’ve learned how to drill teeth, they can learn how to say, ‘thank you, good job.’ It’s a skill; it doesn’t have to be a personality trait.”

Such encouragement enhances a stress-free workplace. “And people are going to want to work for someone who is supportive,” adds Mancusi.

Stressed patients

Add to the dentists’ business responsibilities the challenges presented by patients, many of whom are there only reluctantly. “Dentists,” observes Nelson, “are eternally confronting the patient who is scared and nervous and quite frequently expressing those things verbally if not demonstrating them physically.”

As patient stress can easily affect the entire office, consultants suggest that dentists take the time to ensure their patients are as comfortable as possible. In his course at Maryland, Grace recommends that dentists, before donning protective gear, spend a couple of minutes prior to treatment getting reacquainted with patients. “That’s a good time to judge a patient’s stress level, and if there is stress they can talk to the patients about questions and concerns they might have. So you get all that out at the beginning, and it helps reduce the stress levels of both the dentist and patient.”

That approach, though, has prompted questions from Grace’s classes. Some students have raised concerns that it might be difficult to stop some patients from indulging in excessive casual conversation and wasting time. “But our experience has been that once the patients see you put on your protective gear, they know it’s time to get to work. I’ve never seen a patient violate that. That doctor-patient conversation is very valuable; it helps relax patients and it allows them to see the dentist as a person.”

One area of a dental practice that needs constant vigilance is the dynamics among the dental team, say consultants. Sometimes dentists get so caught up in their own work that they don’t see problems brewing. They might keep their eyes open for the classic signs of stress, such as sleepiness (insomnia) and irritability.

Also, says Mancusi, “company politics are magnified in a dental office because it’s so small. It’s like a pressure cooker; any problem at all is totally disruptive. So dentists need to be aware of what’s going on in their offices, because [troubles] will certainly spill over on them. And the first thing they need to do is listen, listen, listen.”

They also need to be accessible to staff seeking answers to problems. The key here is communication, says Drevenstedt. “I find that offices which best manage team stress are the ones that really work on improving their interpersonal communication. A lot of stress in the workplace has to do with interpersonal conflicts.”

Drevenstedt advises dentists to have regular meetings during which staff members can talk about problems, and provide team building/stress-management reading materials and workshops.

Mancusi suggests daily meetings: “Sometime in the middle of the day, bring everybody together so that they can ask questions, bring up issues, talk about what’s going well, what’s not, what problems have occurred and their possible solutions. I’d do this daily for five to eight minutes.”

Such abbreviated meetings can even be a starting point for addressing interpersonal problems, he continues. “One of the things that starts happening during these meetings,” Mancusi says, “is that by the third day or so people start bringing up communication issues: ‘Jane, I noticed yesterday that you slammed something down, what was wrong?’”

To help ensure a low-stress office, dentists also need to respond to staffers’ personal lives, adds Mancusi. “For example, if someone wants to go back to school, you can allow special arrangements so that person can leave at 2 p.m. instead of 4 p.m. Or if someone is going through a divorce, you might make some allowances for some emotional things you’re seeing. Responding to your workers’ private lives will help the dentist and the practice in the long run.”

One prime resource for pointers on reducing office stress is the dental community itself, say consultants. “Dentists can find professionals in their area or [dental] association who are having a good time in dentistry and then network with those people to learn their successes and secrets,” says psychologist Frey. “That’s always a good option.”

Dr. John Gammichia of Orlando, for instance, wouldn’t think of doing anything other than dentistry. At the same time, he’s well aware of its attendant stresses and tries to meet them head on. He knows, for one, how easily troubles with treatment plans can heighten stress.

Recently, Gammichia ran into unforeseen problems with a patient’s crowns. “I was doing three crowns for a woman and it all seemed very straightforward,” he says. But shade matching proved to be an obstacle.

Three times the patient kept her appointment for the crown seating and on each occasion either she or Gammichia objected to the shade provided by the lab. Frustration was pervasive.

Finally, Gammichia decided to go back to square one, at no extra cost to the patient. “I’m going to re-prep her teeth and we’re going to try a different [restorative] material,” he says. “Now the quest is to make it right and please her; by the end it better be so good that she feels it was worth her wait.”

What helps ease frustrations for patients, says Gammichia, is that he puts a high priority on maintaining  “great relationships” with everyone he treats. For the woman with the crowns gone awry, for example, Gammichia sent her flowers, apologized for the difficulties she experienced and assured her that through it all she had been “a terrific patient.”

What helps Gammichia deal with disappointments in the office is a combination of things. “First of all,” he says, “I love my job and that gets me through.”  Adding some perspective plays a part, too.

For each treatment problem he encounters, he also knows there are many more occasions when everything went smoothly. “Every two weeks or so I get a thank you card, and that helps keep me going,” he adds.

Daniel McCann, senior editor of Dental Practice Report, can be reached at dmccann@advanstar.com.