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The sum of all fears

18 November 2019

It is a fact that much of human behaviour is related to maximising rewards and minimising losses. Raj Rattan, dental director at Dental Protection, looks at how we can reduce fear and manage risk and uncertainty, so we can stay confident and competent throughout our careers.

The view that success breeds success is explained by neuroscience as the result of a surge in the neurotransmitter dopamine. This reward chemical encourages the brain to carry on doing what it has been doing – it is an example of ‘reward-based learning’. We also learn from failure – so-called ‘avoidance learning’ – where the absence of a stimulus creates a behavioural change. It correlates with the expression of fear.

Feeling the fear

It is a widely expressed view that dentists are now more fearful than ever. We hear it from members, from professional bodies, from those involved in postgraduate education including training programme directors who are in regular contact with dentists at the start of their professional careers.

The fears relate to the consequences of failure, reprimand, and loss of reputation. It impacts self-esteem and may lead to loss of confidence in carrying out clinical procedures, especially when there are pre-existing concerns and self-doubt about clinical competence. These fears are expressed by dentists and the voices have never been louder.

In a bygone age, these voices were heard only by those within earshot. Today, the extended reach of social media means the world can listen and replay. Fears are amplified and this leads to vicarious fear learning; it appears without any direct contact with the stimulus. An individual learns from another by observing their response to a situation. When one person posts a comment, all readers feel the fear.

Important details are frequently omitted in commentary about dentolegal cases; information and misinformation blended to occupy the same space. Details are a distraction, enforced brevity an asset. This brevity curse has claimed many victims. Incomplete or inaccurate information in bitesized pieces is easy to exchange and share with the world. It is out there – available to everyone at all times of the day and night.

It leads to availability bias – a type of cognitive bias that distorts the way we see the world. Information that comes to mind quickly and is covered by the media makes us believe that it is very common. Its swift passage through modern communication channels leads inevitably to the bandwagon effect.

Experiments have shown that if a large proportion of people adopt a particular view or stance, then there is a greater probability that others will adopt the same position (regardless of their beliefs). These psychological biases can skew reality, making us feel more vulnerable than we should. In other words, we judge probability by how easily the information comes to mind rather than the mathematical construct it is.

Competence and confidence

Fears related to competence may also be influenced by self-perception, but many are well supported. Our experience of dentolegal cases tells us much about the factors that contribute to suboptimal outcomes that form the basis of complaints and litigation.

There are situational and systemic predisposing factors. These include time shortage, target-driven payments systems and other related commercial factors. Studies suggest that unfamiliarity with a task significantly increases the likelihood of error. This is a competency issue and we observe this in a significant number of cases.

Competence is a precursor to doing things right. It is a blend of three ingredients that are required in abundance – procedural knowledge, exposure to varying levels of complexity, and experience. Whilst we often stress the importance of comprehensive and contemporaneous record keeping, the outcome of a case built on competence related issues is unlikely to be successfully defended on the standard of record keeping alone.

Measurement of competence is the key – both at undergraduate and postgraduate level. There have been many developments in educational theory in the last 100 years, but Flexner’s assertion (1910) that “there is only one sort of licensing test that is significant: a test that ascertains the practical ability of the students confronting a concrete case to collect all the relevant data and to suggest the positive procedures applicable to the conditions disclosed” holds true today. Emotional intelligence, empathy and effective communication may mitigate the consequences of competency-related failures but are not a substitute.

In his thesis, Roudsari (2017) discusses aspects of foundation training in the UK. He writes that “from the trainers’ point of view and based on a recent qualitative study, however, it has been shown that the majority of the newly qualified dentists are far from being competent, in particular due to lack of experience in a number of key dental procedures; for example, endodontics and extraction of teeth with difficulty levels of moderate to hard”.

Many foundation dentists that visit us each year during their foundation training express similar concerns. It compounds the fear. We provide bespoke educational programmes to help them overcome these fears and other professional challenges at a critical part of their professional development. We can however do little to increase their clinical competence other than stress its importance as a key risk management principle and suggest solutions to the dilemma.

Literature relating to pre-foundation training competence is scarce because, according to Roudsari, “most of the publications focus on ‘confidence’ of the graduates and not their ‘competence’”.

This presents another challenge because an over-reliance on confidence is not without its drawbacks. Confidence is a double-edged sword from a dentolegal perspective. David Dunning and Justin Kruger – Nobel Prize winners for their work – demonstrated the overestimation of performance by individuals of low competency levels. It is observed at low levels of experience, because at this stage an individual has little or no insight into their weaknesses. As a result, these individuals are particularly at risk because they don’t know what they don’t know. It is equally true at the beginning of a person’s career as it is at any stage where a person undertakes postgraduate study to learn new skills.

So, how does a dentist ensure they have the appropriate level of training to undertake clinical procedures? Not all postgraduate courses offer the same training opportunities and there may be different levels of clinical supervision available.


Patients expect us to be competent. Competence-related issues are as important as all other contributory factors to effective risk management. We have an ethical obligation to evaluate outcomes and assess personal competence to avoid straying – intentionally and unintentionally – beyond our areas of expertise and training, propelled by misplaced confidence and perverse incentives.

Recognising the influence of availability and bandwagon bias is the first step to deal with risk and uncertainty, and estimate probabilities accurately. It’s about being able to gauge the limits of our own knowledge, knowing when we don’t know much, and being confident when we do. This contributes to our risk intelligence.

If we are to reduce the sum of all fears, then individual practitioners, educators, regulators and government agencies have an important role to play to understand and address the root causes. The future depends on it.

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