Introduction The dental profession is facing a serious crisis. It is a disease but not in the usual way we think of disease. The disease is in the model of delivery of the service and the levels of mental stress and anguish being heaped on our young colleagues with over regulation and the subtle attacks on the dentist patient relationship as we replace the patient with ‘the consumer’ and real problem solving for the people we serve with glossy advertisements that do not reflect normal life.The following is taken from an article by Endodontist, Mark Bishop in the British Dental Journal (2018). where the serious dysfunction in the General Dental Council is highlighted.
‘Young and enthusiastic, hard-working dentists have been moved to write to the British Dental Journal about their plight. For example, Al Hassan has networked with many young dentists who felt vulnerable, stressed and upset. The causes of these anxieties were almost never the dentistry but were financial issues and the GDC. On the GDC, Al Hassan describes ‘colleagues being dragged through the coals over minor infractions which have nothing to do with public safety.’ And dentists being ‘subject to so much stress and mental degradation that their patient care will inevitably suffer. The whole profession begins to act much more defensively as a result, leading to worse outcomes for patients.’ Not surprisingly, dentists don’t want to work in general practice and seek more sheltered environments or go abroad. This is creating an unsustainable environment for dental care. As Al Hassan exclaims, ‘We can’t let this continue’ and ‘We are on the cusp of a mental health crisis.’
Martin Kelleher has used the term ‘State-sponsored terrorism’ to describe the horror of GDC inquisitions which seem bent on destroying the dentist’s reputation. This are serious words from a well known and very well respected accredited specialist in restorative dentistry. We need to listen and take it seriously. Action is urgently needed. We cannot call ourselves scientific if we refuse to acknowledge that what we are producing is toxic while the evidence is all around us.
A Dental Council is a body that is charged with the regulation of the profession in the interests of patients. It wants to protect the patient and that is a noble pursuit. As such it is a kind of parent body for the practice of dentistry. The problem occurs when care is misunderstood. The core misunderstanding is that care is partisan. Care is always inclusive if it is to be called care. To say the we damage one group in order to care for and protect another group is insane. But this is what is happening in our profession.
It is akin to a parent beating his own children in order that they do not hurt others. It is not difficult to see that such an approach lacks reason. This is particularly so when a dentist is required to care for patients while the governing body treats the dentist with contempt and ill-will in order that the dentist will provide proper care for the patient. How insane can it get? Well clearly to the point of destroying the health and well being of the dentist while supposedly protecting the health and well being of those the dentist serves. How can a pressurised and overburdened dentist provide care?
I work with dentists suffering from stress and burnout, so I know first-hand the incredible strain that many are enduring while trying to provide care to others. I can tell you that this is not sustainable, and we are heading for catastrophe as a profession.
The corporate problem One of the consequences of dentists (and doctors) not being cared for by the regulatory system is the increasing appearance and domination of Corporate Bodies providing dental or medical care. These bodies use dentists to create a business model but sadly follow the ‘poor parent’ model of the GDC. In a time where money is not easily available for young dentists/doctors to start or buy a practice, large corporations have funded large practices and attracted dentists to work for them. This need not be a problem, but the model used is proving to be a real vexation for the dentists. The essential issue is that the dentist carries all the responsibility of patient care and the insurance indemnity as well as taking the status of being self-employed. However, the dentist has no power in the practice to regulate or oversee that patient care. That function is invested in the practice manager who, although well meaning, often does not understand or appreciate the importance of the dentist/patient relationship and the burden of responsibility of the dentist to provide quality care.
The middle management tend to want to see profit which is understandable but appear oblivious to the needs and issues of the dentists at the chairside. Often equipment is not being kept in good working order and the dentist must put up with problem equipment while still trying to maintain good dentist/patient relationships. Other times fees and special offers are decided by management without consulting the dentist who must fall in with these demands even if they tend to violate good practice or quality care. The company can fail the dentist with no consequences but there are consequences if the dentist fails the company. The business model thus undermines the care model. That is the essential dysfunction that results from the core function of chairside service being divorced from the company function. This is the imbalance in the power structure.
The associate dentist contract often does not have provision for dentists to voice opinions or concerns and when she/he does so, it is often viewed as criticism and working relationships can deteriorate very quickly. In this the dentist is rarely supported, while the staff are given every support in what has become a very much ‘us and them’ mentality. The staff, including nurses, who traditionally worked as chairside assistants, are now wedded to the corporation management and disrespect for the dentist is common. I have personally seen this first-hand. The Facebook page Mental Dental (a page for dentists in crisis which has over 40,000 members) is replete with heart-rending stories of pain and anguish which if not related to GDC abuse is related to Corporate mismanagement and unfair practices.
The Government Dimension Mark Bishop says of the Government-funded British system ‘The system of NHS general dental practice is considered in terms of quality and humanity and found to be failing in quality and lacking in humanity.’ We are not far behind here in Ireland. Our Medical Card system in dentistry is nothing short of appalling. With expectations of high standards of care for patients it offers fees that make that standard impossible except at financial loss to dentists. The regulations are often directly in opposition to best practice where extractions and dentures are favoured above conservation and prevention. As a profession we are insulted by a pretence of negotiation by Government and 35 years after being asked to work the ‘ad hoc’ system, as a concession while reform would be implemented over time, we find ourselves with an even worse ‘ad hoc’ system and no hope of reform. It is time to recognise that government has no interest in health or in dental health. The interest is feigned to keep power and appearance.
The problem is again the imbalance of power. The crises in the practice of dentistry are ignored by Governments that only pretend to care, the academics who do not see that they have a role in the reality of practice, while being responsible for the curriculum that is creating the professionals that find themselves so burdened in dysfunctional unfair systems and the Dental councils that do not see their role in the care of the professionals that they regulate. All in all, it’s a horrendous parental failure, a failure of those in a position of power to rule fairly and honestly.
The profession must now learn to take power back and say no to systems that are unfair and dysfunctional and that are clearly not producing good fruit. We must, in hand with our medical colleagues, stand up to injustice. We must insist on education that includes communication and human behaviour, so long established as the core of the painful problem of litigation and we must insist that we will not support models and systems that need repair and restoration to create fairness and justice.
The corporate entities could do so much to help the profession of dentistry, but they must return to the centrality and sacredness of the dentist/patient relationship and the patient before profit mindset. The dentist must have power returned and burdens and responsibilities shared in a mutually beneficial relationship. Otherwise, they contribute to the demise of the profession and the demise of the health and well-being of the individual dentists. These individual dentists are the life blood of the corporate entities and there will be no survivors if the very blood is allowed to become more septic even unto death.
I am putting all parties on notice that dentistry belongs to the dentists and that we are reclaiming the power that rightfully belongs to us. I would call upon my colleagues to get in touch and support this cause. My email address is [email protected]
By way of introduction, my name is Philip Christie and I qualified in Dentistry from TCD in June 1980. I completed an M. Dent. Sc by research with Professor Noel Claffey (TCD) in Periodontology in 1995 and then completed an M.A. in Cognitive Behavioural Therapy on the subject of the Dentist/Patient relationship in 2015. My lifelong career interest has been in the human factor (the subjective) as it relates to clinical practice and in dealing with dental anxiety and phobia. My work embraces the practice of dentistry and working with dentists who are experiencing mental health issues like anxiety, stress and burnout related to clinical practice.
My research in the Cognitive Behavioural area concerned the issue of dentist/patient relationship and the barriers to communication, which is correctly cited as being the central factor in litigation. This research threw up many serious issues which likely need to be addressed in the educational curriculum of both undergraduates and postgraduates alike.
As an example, my work on the dentist/patient relationship clearly pointed to what I call essential miscommunication. This is miscommunication at its most fundamental level.
The best way that I can describe this is in terms of language. People who do not have Irish as a language cannot understand a person who is speaking the language. My work pointed out such a huge disconnect between dentists and patients that it was akin to not having the same language. It was clear that the world and experience of people had only a small and limited overlap with the clinical dentist. This resulted in words which were used by the dentist in an attempt to signify objective findings being misinterpreted by the patient who has no internal data set for the ‘objective’ and created a real ‘us and them’ polarity.
This, and other research findings, are what I try to address in my courses which can be found here. The first objective is to relocate the clinical dentist in his/her own humanity as a subjective being and from that place connect with the ‘patient’ as an equally subjective person first – only then bringing the tools of dentistry to offer service to them.
The phenomenological study that was the core of my research work also identified many other areas of problems and disconnect. Clearly, all of this has a tremendous impact on the dentist/patient relationship. When this relationship is further undermined as a result of dysfunctional government systems, dysfunctional regulatory requirements or misconstrued corporate delivery structures, the result is a degenerative mess. The impact is on dentists, staff and most especially on patients and patient care. All of the confluent factors need to be addressed to correct and restore the profession and its ability to care for those we hope to serve.
References (adapted from the article by Mark Bishop 2018)
1. Al Hassan A. Defensive dentistry and the young dentist – this isn’t what we signed up for. Br Dent J 2017; 223: 757–758.
2. Bishop M.A. The patient-dentist relationship and the future of dentistry. Br Dent J 2018; 225: DOI: 10.1038/sj.bdj.2018.1035
3. Kelleher M. State-sponsored dental terrorism? Br Dent J 2017; 223: 759–764.
4. Hussain M G. A dental student’s journey to joining a profession which is failing the very people it cares for. Br Dent J In Pract 2018; 31: 20–21.
5. Ward P. Human beans. Br Dent J 2014; 216: 543.
6. Ward P. The entrepreneurs at the GDC. Br Dent J 2014; 217: 549.
7. Sellers J J. ARF Hike – You cannot be serious. Br Dent J 2015; 218: 212.
8. Marks C. Get off our backs. Br Dent J 2015; 218: 212.
9. Pairman J S. The dental police force. Br Dent J 2015; 218: 212.
10. Bell M. Gross miscarriage of justice. Br Dent J 2015; 218: 92.
11. Renshaw J. Serious concerns about the General Dental Council’s performance and direction of travel. Br Dent J 2018; 224: 213–214.
12. Hancocks S. yCPD. Br Dent J 2018; 224: 195.
13. Hancocks S. What if? Br Dent J 2017; 217: 257.
14. Hancocks S. Again and again and will it be again? Br Dent J 2017; 223: 797.
15. Ward P. Whistling in the dark. Br Dent J 2016; 220: 1.
16. Westgarth D. Going through the motions. Br Dent J In Pract 2018; 31: 7.
17. BDJ News. GDC chair must go says British Dental Association. Br Dent J 2016; 220: 47.
18. Armstrong, M, Ward P. The GDC – a law unto itself? Br Dent J 2017; 223: 815–818. 19. Harlow R. Just another number? Br Dent J 2011; 211: 306.
19. Rossi M. NHS dentistry – UDA disaster. Br Dent J 2016; 221: 279.
20. Hancocks S. The Birthday party. Br Dent J 2018; 225: 1.
21. Wilson N. Presidential address. Br Dent J 2015; 218: 503–504.