How Dentists See Themselves, Their Profession, The Public

TRENDS

HOW D E B SEE THEMSEEVES,

THEIR PROFESSION, EHE PUBLIC B A R B A R A G E R B E R T , PH .D .; J A N E B E R N Z W E IG , P H .D .; T H O M A S B L E E C K E R , P H .D .; J A M E S BADER, D .D .S ., M .P .H .; C A R A M IY A S A K I, M .S.

(¿ ^ tu d ie s traditionally show th a t dentists feel mostly positive toward th eir profession. Although not all dentists are equally affirm ative in this view,1the overall impression from past research is th a t dentists have been largely contented with dentistry as a career.2'5 In a 1977 study of Columbia U niversity alum ni, for example, 82 percent of respondents indicated they would again choose dentistry as a career.3 Sim ilarly, a 1968 survey of graduates from the D ental School of the London Hospital Medical College found th a t only 19 percent of respondents said th a t they would not again make d entistry th eir career choice.5 D entists’ level of ■satisfaction w ith their profession, surveys show, is related to age,36income,3'7relations with p atien ts4 and level of stress,8-9 among other factors. W hatever the source, d entists’ positive feelings tow ard the profession have been im portant in successfully recruiting prom ising young people into dentistry.1011 The high regard dentists have for their profession traditionally has been shared by the : public. Polls show th at, in isolation12 and in relation to other professionals,13 the public has long held dentists in high regard. Such respect from the public in general and 72

JADA, Vol. 123, December 1992

ABSTRACT

The public traditionally has held dentistry in high regard as a profession. But some recent evidence suggests a decline in public confidence— a fact that may be affecting the w ay dentists view themselves. What should and can be done? from patients in particular has been considered an im portant component of dentists’ positive feelings about th eir profession.2 11 Shugars and colleagues exam ined California dentists’ overall satisfaction, as well as th eir views about income, respect from the public, stress, the quality of non­ work life, the process of delivery of care and patient relations.2 These researchers found th a t j dentists’ overall professional satisfaction was strongly correlated to th eir perception of the respect accorded them by the public—and th a t such public respect was the m ost im portant factor influencing dentists’ overall professional j satisfaction. In the last several years, dentists’ sense of contentm ent w ith th eir careers has been sorely

image of dentistry and the elem ents th a t affect th a t image, we performed a national survey of a random sam ple of U.S. dentists.

PERCENT ENDORSING

50

-------------------------------------------

M ETHO DS

A FEW

SOME

MOST

ALL

Figure 1. How many of your colleagues would you go to for dental care (N = 1,221).?

tested. D entistry has had to endure high levels of scrutiny and criticism . The transm ission of HIV to patients in a dental office,15renew ed controversy about the safety of am algam restorations (“60 M inutes,” Dec. 16, 1990) and the safety of infection control procedures related to dental handpieces (“S treet Stories,” May 21, 1992) have all draw n critical public atten tio n tow ard dentistry. Recently, some leading dental professionals have expressed concerns th a t media stories about potential hazards of dental care for patients m ight be dim inishing th e public’s tru s t in, and image of, the dental profession.1617 F u rth e r­ more, the practice of dentistry has changed radically. D entists have to calm p atien t concerns about safety,18 comply with increasingly stringent infection control protocols19 and compete economically w ith other den­ tists. Along w ith these changes, dentists no longer experience the professional autonom y they once knew .20

The recent negative media attention, the possibility of a decline in public respect and the changes in dental practice may be causing some dentists to have misgivings about their own profession. These m is­ givings could affect dentists’ stress levels, th eir career satis­ faction and th eir enthusiasm in recruiting new students for dental schools. Researchers have examined d entists’ overall satisfaction with the profession and th eir satisfaction with specific components of it. Most studies, however, have used sam ples of dentists from narrow geographic areas. To our knowledge, no studies have investigated a random sam ple of U.S. dentists to ex­ plore th eir views on dentistry’s image or th eir beliefs about the public’s image of the profession. Since public respect is a signif­ icant component of dentists’ professional satisfaction,2 it is im portant to investigate den tists’ beliefs about the public’s current view of dentistry. To u n derstand w hat dentists think about the public’s

In A ugust 1991, we m ailed a questionnaire to a represen­ tative random sam ple of 2,081 U.S. dentists. D ata were collected as p a rt of a larger study of dentists’ opinions on issues challenging dentistry in the 1990s.18 The m ailing list was purchased from the ADA and contained nam es of Association m em bers and non­ members. Demographic characteristics were available from ADA files. The 58-item questionnaire had been pilot tested for face validity, ease of adm inistration and readability. It covered three areas: « dentists’ perceptions of the public’s im age of dentistry; ■* w hat factors dentists believe have affected the public’s image of dentistry; ■■ w hat dentists th in k should be done to improve the public’s image of the dental profession. Two weeks after m ailing the questionnaire, we sent a rem inder postcard to non­ respondents. New copies of the questionnaire were sent to non­ respondents three weeks after the original mailing. The re ­ sponse rate was 62 percent. A total of 1,262 subjects re ­ sponded, with 57 inéligibles (retired, for example). This re ­ sponse rate is considered good for surveys of health care pro­ fessionals.21 The sam ple’s demographic characteristics and post-stratification proce­ dures th a t we employed have been previously published.18 JADA, Vol. 123, December 1992

73

RESULTS

Overall, 87 percent of our sam ple believed th a t the public image of dentistry is “g reat” or “good.” Only 1 percent reported th a t the public’s image of the profession was “terrible,” though 74 percent said they thought dentistry’s public im age needed improvement. As an indirect m easure of den tists’ feelings toward their profession, we asked respond! ents w hat they would advise young people regarding denj tistry as a career choice, and w hether they them selves would choose dentistry as a career today. U sing these indexes, den tists’ lack of ease with the profession was apparent. Only 54 percent of our sam ple said th a t they would recommend dentistry as a career to a young person, and ju s t 50 percent indicated they would again m ake dentistry th eir own career choice. ADA m em bers apparently j view the profession slightly more positively th an do nonj ADA m em bers. Of those den­ tists who were ADA members, i 58 percent would recommend a

career in dentistry to a young person, and 54 percent would choose d en tistry as their own career today. For non-members, 41 percent would recommend a dental career to a young person, and 36 percent would choose dentistry a second time as their own career. O ur findings con­ tra s t greatly with previous studies, which found much higher percentages of respond­ ents indicating they would again choose a career in dentistry.3'5 Confidence in dental colleagues could also indicate how dentists view their pro­ fession. To assess this, we asked dentists from w hat proportion of th eir colleagues they would be willing to seek dental care. Figure 1 shows the distribution of th is variable. As illustrated, only 2 percent of respondents said th a t they would go to “all” of th eir colleagues. FACTORS DENTISTS BELIEVE ARE AFFECTING THE PROFESSION’S IMAGE

We wondered w hat factors dentists believe are affecting dentistry’s public image. Most

NUMBER OF DENTISTS

700

600

500

400

300

200

100

1% OR LESS

>1% TO 10%

>10% TO 20%

>20% TO 30%

>30% TO 40%

>*40% TO 50%

>50%

Figure 2. Percent of patients expressing concern about amalgams (N 1,115).

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JADA, Vol. 123, December 1992

respondents (92 percent) saw sensationalism in the m edia as harm ful to the public’s image of the profession. Eighty-seven percent said the report of HIV transm ission from a dentist to his p atients had damaged the public’s opinion of dentistry, and 81 percent felt th a t colleagues who advertise their negative-HIV sta tu s also harm dentistry’s public image. Sixty-one percent of our sample believed th a t concerns over the safety of dental am al­ gam have dim inished the public’s image of dentistry. However, fewer dentists believed th a t concerns over the safety of fluoride (18 percent) and the cost of dental care (39 percent) have harm ed the public’s image of dentistry. M any respondents also identified advertising practices | as harm ful to the profession’s image. Fifty-nine percent of our sample felt th a t telephone serv­ ices th a t provide referrals to local dentists harm dentistry’s j public image. As an open-ended question, we asked dentists w hat practices used by other dentists to promote their businesses detract from the image of dentistry. Sixty-five percent of th e 303 responses given m entioned advertising. Several factors were thought to influence a positive image of dentistry. Sixty-five percent of : respondents believed w riting dental inform ation pieces for local new spapers improves the profession’s image, and 79 percent felt th a t the ADA’s hiring of a public relations firm to boost dentistry’s image was an appropriate use of ADA resources. In addition, 57 per­ cent believed the ADA should ! spend more money improving the profession’s image.

1 % OR LESS

>1% TO 10%

> 10% TO 20%

> 20% TO 30%

> 30% TO 40%

> 40% TO 50%

>50%

Figure 3. Percentage of patients expressing concern about HIV transmission (N = 899).

To arrive a t a global index of dentists’ views of th eir pro­ fession, we carried out a Principal Components Analysis using 12 questionnaire item s. This analysis revealed three factors th a t accounted for 51 percent of th e variance (Table 1). Factor 1, which accounted for 27 percent of the variance in dentists’ responses, was labeled “O utside sources th a t h arm the image of dentistry.” Factor 2, accounting for 14 percent of the variance in den tists’ responses, was labeled “Feeling th a t den­ tistry gets no respect.” Factor 3, accounting for 10 percent of the variance, was labeled “The image of dentistry over tim e.” Subjects received scores on each of the three factors. These factor scores reflected th eir weighted responses on the variables th a t constitute the factor. In other words, dentists would have a high score on Factor 1 if they “strongly agreed” (scored 5 on a 1-5 scale) th a t sensationalism in the media, the concern over the safety of dental am algam and the report of HIV transm ission

by a dentist to patients have dam aged the public image of dentistry. These scores were used as sum m ary m easures to determ ine correlates th a t m ight underlie dentists’ image of the profession. C O R R E L A T E S O F IM A G E

One elem ent th a t we thought m ight influence dentists’ image of the profession was the extent to which th eir patients expressed concerns about issues of dental safety. We thought th a t dentists who had higher num bers of p atients expressing concerns about dental am algam and HIV transm ission would score higher on the factors—th a t is, have a more negative view of the profession. We hypothesized th a t dentists m ay be uncom­ fortable or uncertain about how to respond to p atien t concerns and th a t this discomfort could lead to negative feelings about th eir profession and how it is portrayed. To assess this, the question­ naire asked respondents to estim ate the proportion of p atients in th eir practice who

had expressed concerns about am algam safety and about HIV transm ission in dental offices. The proportion of p atients who expressed concerns about these issues is shown in Figures 2 and 3. As predicted, we found a positive relationship between I the proportion of patients with concerns about dental safety and our factor scores. D entists who had a h igher proportion of patients who expressed con­ cerns about dental am algam were more likely to agree th a t outside sources h arm the image of dentistry (P < .001), and to believe th a t dentistry gets no respect (P < .01). Likewise, dentists w ith a higher propor­ tion of p atients expressing concerns about HIV tran sm is­ sion were more likely to believe th a t outside sources harm the image of dentistry (P < .001), and to feel th a t dentistry gets no respect (P < .001). We also wondered w hether dentists who tre a t a higher proportion of HIV-infected patients in th eir practices would have more negative feelings about the profession. To assess this, we asked respond­ ents to approxim ate the num ber of HIV-infected p atients they see in an average m onth (mean = 1.36) and the total num ber of patients seen in an average month (m ean = 273.10). By dividing the two num bers, we created a ratio representing the proportion of patients with HIV infection in our respond­ ents’ practices. Those who saw a higher percentage of HIVinfected patients had a greater proportion of th eir patients express concerns about becoming HIV infected during dental procedures (P < .001). We also exam ined w hether JADA, Vol. 123, December 1992

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demographic differences (such as age, region of the country and ADA m em bership) were related to differing images of dentistry. To evaluate this, we com­ pared th e demographic vari­ ables of those dentists who scored in the upper 25th per­ centile on each factor to those who scored in the lower 25th percentile. We found no differ­ ences in factor scores depending on the census region of the country w here a dentist worked. However, we did find significant differences in the factor scores according to age and ADA m em ­ bership. Those who believed th a t outside sources harm the image of d en tistry tended to be younger (m ean age = 45.4 vs. 48.6, P < .001). Those who felt th a t d en tistry gets no respect also tended to be younger (mean age = 45.4 vs. 48.6, P < .01). However, those dentists who believed th a t th ere will be nega­ tive changes in dentistry’s image over the next five years tended to be older (mean age = 48.7 vs. 45.8, P < .01). ADA m em bers, more th an ADA non­ m em bers, tended to believe th a t dentistry does get respect (P < . 001 ). DISCUSSION

Though th e public and dentists alike historically have viewed the dental profession positively, our national survey suggests th a t den tists’ current feelings about the profession are sur­ prisingly gloomy. M any practic­ ing dentists feel positively about the profession, b u t equal num bers are concerned about dentistry and its future. Only h a lf of our respondents said they would recommend den­ tistry as a career to a young person, and only half indicated 76

JADA, Vol. 123, December 1992

they them selves would choose dentistry as a career today. W hat m ight account for the troubled view th a t m any dentists apparently now have of th eir profession? M any of our respondents fault the m edia for sensation­ alizing the cases of HIV tra n s ­ mission to dental patients in Florida and for airing the latest controversies about the safety of dental am algam . We found th a t dentists who had a higher pro­ portion of patients who ex­ pressed concerns about these

Patient perceptions of dentistry are influenced heavily by their personal dentist, and a positive image of dentistry can be nurtured in dental offices by competent, caring dentists and their staffs. issues tended to express more negative feelings about their profession. It m ay be th at, in the light of m edia scrutiny, dentists experience patient concerns about the safety of dentistry as pressure upon them . U nfortunately, the current m edia controversy about handpiece sterilization may only exacerbate this trend. D entists who hear m any patient concerns may end up feeling unappreciated and distrusted by th eir own patients. As one respondent said, “D entists are negative because of the nega­ tivism placed upon them . Den­ tists have to be super positive now, especially in a tim e of such adversity cast upon dentistry.” A nother problem area for

m any dentists in our sample was concern about the com­ petence and practices of their colleagues. Fewer th an h a lf of the dentists in this sample would go to “m ost” or “all” of their colleagues for dental care. W hat’s more, m any dentists criticized the dental work done by others and the “cutthroat” activities some colleagues use to build business. A m ajority of the dentists sampled believed th a t dental advertising, w hether publicizing negativeHIV serostatus or directly soliciting referrals, is harm ful to the profession’s image. On a more positive note, it appears th a t m em bership in the ADA is associated with a som ew hat better view of the profession’s image. ADA m em ­ bers are more likely th an non­ m em bers to report th a t they would recommend dentistry as a career to a young person, and to indicate th a t they them selves would choose dentistry as a career again. However, even these figures are surprisingly low: 58 percent of ADA m em bers would recommend dentistry to a young person and only 54 percent would choose dentistry again as a career. D entists also appear to be looking to the ADA for a solution to the image problem. The m ajority of dentists in our sam ple supported the ADA’s decision to hire a public relations firm to improve the profession’s image, and also approve of the ADA spending more money in this area. Several lim itations of our study are im portant to note. O ur cross-sectional design does not allow us to m ake causal inferences (w hether being an ADA m em ber m akes dentists more satisfied, for example, or

TA B L E 1

enas FACTOR

FACTORS AND ITEMS

LOADINGS Factor 1 . Outside sources tha t harm the image of dentistry

S e n s a ti o n a li s m in t h e m e d ia h a r m s t h e

.7 5

p u b lic ’s im a g e o f d e n tis tr y * T h e r e p o r t o f t r a n s m i s s i o n o f A ID S to

.7 3

p a t i e n t s by a d e n t i s t is d a m a g in g t h e p u b lic ’s o p in io n o f d e n tis tr y * T h e c o n c e rn o v e r t h e s a f e ty of d e n ta l

.6 2

a m a lg a m h a s h a r m e d t h e p u b lic ’s o p in io n o f d e n t is tr y * Factor 2. Feeling that dentistry gets no respect

T h e o v e ra ll p u b lic im a g e o f d e n t i s t r y is

.7 7

'

D e n ti s t s a r e w e ll-r e s p e c te d by t h e

-.7 4

p u b lic* I feel d is c o u r a g e d b y h o w p eo p le

.6 2

p e rc e iv e d e n t is tr y * T h e im a g e o f d e n t is tr y n e e d s

.5 0 IMPLICATIONS OF FINDINGS

im p ro v e m e n t* Factor 3. The image of dentistry over tim e

I s y o u r im a g e o f d e n t i s t r y b e t t e r o r

.8 2

w o rse n o w t h a n i t w a s fiv e y e a r s ago?:;: Do y o u th ink : t h e p u b lic ’s im a g e o f

.8 2

d e n t i s t r y w ill b e b e t t e r or w o rse five y e a r s fro m now ?§ Do y o u b e lie v e t h e p u b lic ’s im a g e of

.5 9

d e n t i s t r y is b e t t e r n o w o r w o rse t h a n i t w a s fiv e y e a r s ago?:|:

* Item s scored as follows: l= strongly disagree, 2=somew hat disagree, 3= neither agree nor disagree, 4=som ew hat agree, 5=strongly agree, t Item s scored as follows: l= g reat, 2=good, 3=m arginal, 4=not good, 5=terrible. i Item s scored as follows: l=m uch b etter now, 2=som ewhat better now, 3=about the sam e now, 4=som ewhat worse now, 5=m uch worse now. § Item s scored as follows: l=m uch b etter in five years, 2=som ewhat better in five years, 3=about the sam e in five years, 4=som ew hat worse in five years, 5=much worse in five years.

w hether dentists who are more satisfied in the first place are more likely to join professional organizations). It also does not reveal w hether our findings represent a tren d over tim e toward increasing professional

samples. Therefore, the ju x ta ­ position of our results with theirs should be interpreted cautiously. It is also w orth noting th a t our results should not be taken to represent the entire picture of den tists’ image of dentistry. Some of the negative feelings expressed by our respondents may relate to factors not asked about in our questionnaire (OSHA regulations, busyness, changes in insurance reim ­ bursem ent p a tte rn s and other factors). The contribution these factors m ake to den tists’ overall satisfaction or dissatisfaction should be investigated. None­ theless, we believe th a t the degree of dissatisfaction found among dentists in our “snap­ shot” is compelling and calls for action.

dissatisfaction among dentists, or ju st a brief downturn. N either of the previous studies reporting high proportions of dentists indicating they would choose the profession again were based on national

W hat m ight be the im plications of our findings for the future of dentists and dentistry? First, the profession m ust acknowl­ edge the disenchantm ent brew ing in both th e public’s m ind and am ong dentists them selves. Longitudinal studies of d en tists’ attitudes tow ard the profession would be useful to docum ent changes. Second, we m u st continue efforts to und erstan d the causes of distress. In th is study, we identified criticism s expressed by dentists about advertising, competition, competence and practices of colleagues—and difficulties dealing w ith patient concerns about safety. Identi­ fying other causes for dissatis­ faction would be useful in attem pts to am eliorate the problems. Third, though organized dentistry has an im portant role JADA, Vol. 123, December 1992

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to p la y in im provin g th e im age o f d en tistry , w e b eliev e th a t d e n tists th e m se lv e s m u st take th e lea d in th is m atter. P a tie n t percep tions o f d en tistry are in flu en ced h e a v ily by th eir p erson al d en tist, and a p ositive im a g e o f d en tistry can be n u rtu red in d en tal offices by com p etent, caring d e n tists and th e ir staffs. O ur fin d in gs are sobering, b ut th e y can a lso be view ed as p r e se n tin g an opportunity for d e n tists to ta k e action to im prove th e situ ation . D en tists m u st find w a y s to inform p a tie n ts and th e gen eral public abou t th e advan ces d en tistry h a s m ad e over th e years, about th e concern d e n tists h ave for th e w ell-b ein g o f th eir p a tien ts and ab ou t th e im portance prac­ titio n ers place on p rotecting p a tie n ts from infectious d ise a se s. E d u ca tin g th e public m u st be v iew ed a s a profession al respon ­ s ib ility e sse n tia l to im proving in d iv id u a l p ractices and d e n tistr y overall. ■ The au th o rs th a n k Reina Galanes and J a n e t Ranney for data gathering and data entry, and Nona Caspers for w riting and editing suggestions. Dr. G erbert is associate professor and chair, Division of Behavioral Sciences, School of D entistry, D epartm ent of Dental Public H ealth and Hygiene, and project director, C enter for AIDS Prevention Studies, U niversity of California, San Francisco. A ddress rep rin t requests to Dr. Gerbert, 74 New Montgomery, Suite 512, San Francisco 94105.

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Dr. Bernzweig is sta ff research associate, School of D entistry, and research psychologist, C enter for AIDS Prevention Studies, U niversity of California, San Francisco. Dr. Bleecker is senior research associate, School of D entistry, and research psychologist, C enter for AIDS Prevention Studies, U niversity of California, San Francisco. Dr. B ader is research associate professor, D epartm ent of Dental Ecology, School of D entistry, U niversity of N orth Carolina, Chapel Hill. Ms. M iyasaki is coordinator of th e dental assisting program , Division of Biological and H ealth Sciences, Foothill College, Los Altos, Calif. 1. Lange AL, Loupe M J, Meskin LH. Professional satisfaction in dentistry. JADA 1982;104:619-24. 2. Shugars DA, DiM atteo MR, Hays RD, Cretin S, Johnson JD . Professional satisfaction am ong California general dentists. J D ent Ed 990;54:661-9. 3. Yablon P, Rosner JF . The career satisfaction of dentists in relation to their age and income. J Am Coll D ent 1982;49(3-4):4552. 4. Koslowsky M, B ailit HL, Valluzzo P. Satisfaction of the patien t and the provider: evaluation by questionnaire. J Public H ealth D ent 1974;34(3): 188-94. 5. Page CMF, Slack GL. A contented profession? A survey of Old Londoner dentists: 1968. Br D ent J 1969;127:220-5. 6. Eccles J, Powell M. The health of dentists: A survey in South Wales. 1965-66. Br D ent J 1967;123:379-87. 7. Romberg E, Cohen L. D entists’ outlook tow ard th eir profession. J D ent P ract Admin 1990;7(l):39-43. 8. Eli I. O ral psychophysiology: stress,pain and behavior in dental care. Boca Raton, Fla.: CRC Press; 1992. 9. O’S hea RM, Corah NL, Ayer WA. Sources of dentists’ stress. JADA 1984;109:48-51. 10. Grogono AL, L ancaster DM. Factors influencing dental career choice. J Am Coll

D ent 1988;55:30-5. 11. Reese EL, H arm an DW. Select—A national program to attra c t highly qualified individuals to careers in dentistry. J D ent Ed 1987;51:87-90. 12. Kreisberg L, Treim an BR. D entists and the practice of dentistry as viewed by the public. JADA 1962;64:806-21. 13. Hugick L, H ueber G. P harm acists and clergy rate highest for honesty and ethics; senators and police decline. G allup Poll News Service May 22, 1991;54(6):l-3. 14. Chapko MK, B ergner M, Beach B, Green K, Milgrom P, S kalabrin N. Development of a m easure of job satisfaction for dentists an d dental auxiliaries. Commun Dent Oral Epidemiol 1986;14(2):76-9. 15. Centers for Disease Control. Update: Transm ission of HIV infection during an invasive dental procedure—Florida. MMWR 1991;40:21-7,33. 16. Meskin LH. A m atter of trust. JADA 1992;123:8,11. 17. Pride J. D ealing with dentistry’s image dilemma. JADA 1991;122(10): 91-2. 18. G erbert B, Bernzweig J , Bleecker T, B ader J, M iyasaki C. The risks of the “Big T hree”: dentist and patien t beliefs. JADA 1992;123(3):82-8. 19. Yablon P, Spiegel RS, Wolf MC. Changes in d e n tists’ attitu d es and behavior concerning infection control practices. Quintessence In t 1989;20:279-84. 20. Romberg E, Cohen L. D entists’ outlook toward th eir profession. J D ent P ract Admin 1990;7(1):3943. 21. Babbie ER. Survey research methods. Belmont, Calif.: W adsworth; 1973:165.