By Dr Annalene Weston, Dentolegal Consultant
In the last month, at least once, concern or worry for a patient, colleague or my place of work has crept into my mind outside my working hours, potentially disrupting my sleep or my home life. Has this also happened to you?
Regretfully, it is highly likely that it has, as this type of anxiety is commonplace and affects more dental practitioners than you would perhaps suspect. This way of thinking is also a precursor to burnout, which has the alarming global incidence of over 50% of dental practitioners at any one time.
My colleague Dr Sam King and I have previously presented the national lecture tour entitled “Under Pressure” as we wanted to start the conversation on burnout.
We want to thank each and every one of you who attended to support the profession, as we cast the spotlight on our mental and emotional wellbeing, and take positive steps to help and protect ourselves and our colleagues.
The response has been overwhelming. It is one thing to be told that every other dental practitioner in Australia is burned out and quite another to have them come up to you in tears, take your hand and thank you for giving them permission to admit how they feel and to talk about it freely.
What is burnout?
Let’s start with what it is not. It is not a sign of weakness, nor evidence that you are ‘less’ than others. It is not a sign that you are ‘not cut out for dentistry’ nor is it evidentiary of a need to ‘harden up’. There are many definitions of burnout, and one we believe best describes burnout in dental practitioners is:
“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.” 
Burnout is a measurable analysis of ‘stress’, with the most commonly used measure being The Maslach Burnout Inventory Triad: 
1. emotional exhaustion
2. low sense of personal accomplishment
3. depersonalisation (an increase in cynicism or distancing ourselves from others)
When you consider these in the context of dental practice:
"Burnout is a condition born out of good intentions. Dentists [sic] who fall prey to it are for the most part unselfish individuals who have painstakingly striven to reach perfection in their careers, pushing themselves too hard for too long, failing to acknowledge their limitations for fear of ridicule or failure."
Depersonalisation can lead to more frequently occurring difficult patient interactions as a practitioner burns out, compounding the problem, and creating overwhelming feelings of; frustration, resentment, angry helplessness, hopelessness and powerlessness. Not only can these load the underlying issue, but also long term stress is damaging to our health.
Finally, dental practitioners suffering from burnout are far more likely to experience an adverse outcome or receive a complaint, as burnout affects all of our body’s systems:
Feelings of failure, guilt, negativity, anger, resentfulness, a loss of sense of humour.
Poor concentration, distancing, ruminating, cynicism.
Work avoidance, habitual lateness, addiction.
Tiredness, lethargy, poor sleep, increased minor illnesses, anxiety.
It is self-evident then that we need to recognise when we are burning out, not only for ourselves, but also for our patients’ safety, and take appropriate steps to manage it.
One important point to make is that burnout is not a sign of weakness, nor evidence that you are any ‘less than others’. Any and everyone will eventually burn out if they carry too much pressure for too long. As pressure does not discriminate, any one of us could be affected at any given time.
Take me back to the start
“It begins at dental school. To even get there we first have to engage our Type A tendencies into overdrive, and strive to hit the top. Top of our class, the leader of knowledge, an expert in all things.”
Studies show that burnout and stress in dental practitioners begins at dental school, with the primary stressors identified as: concerns about manual dexterity, reduced holidays with increased difficulty of coursework, moving away from home, clinical transition and staff inconsistency.
Naturally, as we exit dental school and progress through our careers, some of these stressors fall away, only to be replaced by fears that are equally damaging. While there is a commonality in the pressures identified across the profession as being most harmful, each country has its own unique factors, deeply rooted in the payment structure and mechanisms of that region.
It would be unsurprising to many then that the Australian specific practitioner stressors have been identified to be time and scheduling pressures, professional concerns (specifically concerns regarding complaints, audits and the regulator), patients’ perceptions of dentists, staffing problems, pressure associated with treatment of patients and business process stressors.
It is not the weight of the burden you carry, but also the length of time you carry it for that is significant. Regretfully, many of our plates are fuller than we would like. External pressures such as ailing parents, young families and even our mortgage payments sit atop our business and clinical stressors, compounding their weight and amplifying the risk of burnout to an alarming level. Having a child under the age of 21 increases your risk of burnout by 54% and, further, having a spouse who does not work as a healthcare provider is reported to increase your odds by 23%. This leaves me, the wife of an electrician and the working mother of six and eight-year-old boys, at a significant risk of burnout. Where does it leave you?
Our own biggest critic?
When we are stretched to the max, our inner voice can unhelpfully chip in when we are at our most tired and vulnerable, psyching us out by whispering in our ear the one thing that we have secretly always feared. Perhaps it is “I am not good enough at this” or “my patients and my staff are all against me”, “I am going to have a career ending complaint” and even “I can’t do this anymore”.
What can we do to reduce burnout?
The more you read about burnout, the more you will learn, and the more solutions will present themselves. This list, however, nicely summarises the steps a dental practitioner can take to address burnout:
1. Avoid isolation and share problems with fellow practitioners
Not only is ‘a problem shared a problem halved’, but there is strong evidence to indicate that increasing your social interactions increases your ability to handle stress and pressure, therefore decreasing your risk of burnout. The evidence base also demonstrates that getting involved in organised dentistry groups can lead to feeling more content and less isolated. 
2. Work sensible hours and take time each day for a leisurely break
We have explored the risks of working Hungry Angry Late and Tired (HALT) many times in our presentations and publications, but to summarise: be your best self to give the best care to your patients.
3. Take time off whenever the pressures of practice start to build
Burnout can mimic depression, so how do you know if you are burned out or if you are depressed? Broadly, burnout will improve with a break or time away from the workplace. Depression does not, so perhaps a good first step is to take a break! Not only will this give perspective about your workplace, and perhaps identify some changes you may wish to take place, it will also help identify whether you need to seek medical help for an underlying condition.
4. Learn how to better handle patient anxiety and hostility and attend courses on stress management and communication skills
With a CPD requirement of only 60 hours every three-year cycle, we would suggest that you consider investing in your soft skills too. Communication can be practised and learnt, and the evidence strongly points to improved communication capabilities decreasing the likelihood of ever receiving a complaint.
5. Adopt a programme of regular physical exercise
Exercise not only serves to release endorphins, but it’s also an outlet for the built-up tension you carry. Developing the positive habit of regular exercise can benefit you, both body and mind, with the benefits of exercise shown to be greater, and longer acting, than taking antidepressants for those suffering mild to moderate clinical depression.
6. Be kind to yourself and less critical and demanding of your efforts
Judging your day-to-day efforts through a clouded filter of negativity will create great distress. Be kind to yourself. You help patients. Every day. Without exception. This is something to be proud of.
Bringing it all together
The problem is real; brushing it under the carpet will not address it, and certainly will not make it go away. It is not all bad news though – burnout is identifiable, perhaps preventable and certainly curable.
Dental Protection would never raise a practitioner problem without providing a solution. For those of you who wish to know a little more about the internal and external factors that lead to burnout, and explore the active steps you can take to gain control of this, our presentation “Under Pressure” is available to view on Prism (members only area).
You may also be interested in our wellbeing resources for members, including access to a confidential counselling service.
If you feel you may be suffering from burnout, don't hesitate to contact us to get the support you need.
 Christina Maslach, Maslach Burnout Inventory Triad, 1981
 Astill S, Ricketts N, Singh L-A et al, Environmental and perceived stress in Australia dental undergraduates: Preliminary outcomes, J Dent Res Dent Clin Dent Prospects 10(4): 270-279 (Autumn 2016)
 Johns RE, Jepsen DM, Sources of occupational stress in NSW and ACT dentists, Australian Dental Journal 60: 182-189 (2015)
 Burnout among healthcare professionals, a call to explore and address this under-recognised threat to safe, high quality care; Dyrbye et al, Perspectives, July 2017
 Dentistry on the couch: Hugh Joffe; ADJ 1996; 41 (3) 206-10
 Stress Management in Dentistry: Mark Grossman, Alpha Omegan. Fall 2014. Pg18-21
 Exercise treatment for major depression, maintenance of therapeutic benefit at 10 months: Babyak et al. Psychosom Med 2000 Sep-Oct; 62(5): pg633-8