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Sources of dentists’ stress
ARTICLES
Six items form a pattern for stress: some are unique to dentistry, others relate to today's fastpaced society.
Sources of dentists’ stress Robert M. O’Shea, PhD N orm an L. Corah, PhD W illiam A. Ayer, DDS, PhD
r
on sid ered by the standards that A m ericans use to assess occupations, dentistry has positive qualities in abun dance, including the high prestige of a profession, and specifically of a health profession; good income; a large measure of independence; individual ownership of an enterprise; opportunity to do good for fellow human beings; participation in an applied biologic science; and consid erable control over the nature, scope, quality, and price of individual labor. These characteristics are well recognized by dentists as they regularly appear in recruitment brochures and in studies of dental school applicants, students, and practicing dentists. These benefits, however, are not abso lute. To some extent, all practitioners are a ls o r e g u la te d and in f lu e n c e d by others— by various government agencies, by insurance companies and, above all, b y th e p a t ie n t s w h o se d e n ta l, psychologic, and social needs set limits to the dentists’ latitude of action and affect the way they experience their own work. Despite all of its advantages, one of the consequences of dental practice is un doubtedly stress.1 Stress is a frequent topic of essays in the popular dental literature. It is a frequent 48 ■ JADA, Vol. 109, July 1984
T a b le 1 ■ Im p a c t o f 2 5 p o s s ib le s tre s s o r s (N = 9 7 7 ). H ow stressful? (%)
Possible stressors Falling behind schedule Striving fo r technical perfection C ausing pain in patients Anxiety in patients Patients late fo r or m issing appointm ents Patients uncooperative in chair Physical dem ands of practice Having to train new assistants Insurance com pany requirem ents G overnm ent regulation Feeling responsible fo r patient’s oral health Patients not com plying with advice Having to contain your ow n em otional reactions Having to o few patients Unrealistic patient expectations Having too m any patients Not m aking enough money Long w o rkin g hours Getting along with staff G etting along w ith patients Lack of patient appreciation Patients not a ccepting the preferred treatm ent To o m uch of sam e kind of work C om petition from other dentists Isolation from other dentists
Not at all
A little
A fair am ount
Very much
13 10 15 10 15 16 22 28 24 26
36 41 43 50 44 46 44 38 43 43
35 36 30 33 29 26 27 25 27
16 13
22
13 8 9 6 9
27 18
44 55
22 22
7 4
23 42 24 45 40 42 33 36 28
51 33 54 33 39 38 50 47 56
20
6 8 4 4 5 4 4 3
50 38 36 26
13 11 9 5
34 49 54 68
17 19 18 16 16 13 14 14
12 8
12
2 2 2 1 1
A R T IC L E S
subject at professional meetings and in continuing education courses on practice m an ag em ent. T here is also a sm all !*• amount of scientific literature that fre quently calls for more research on the sub ject. In one review, Gift2 was particularly concerned about the inadequate and con flic tin g evid en ce for various g en er alizations and folklore about dentists’ mortality, suicide, and divorce. *. Godwin and others3 asked a sample of recent graduates to identify sources of the
and psychologic measures of 33 Canadian dentists and related a number of stress symptoms to time pressures at work and also to exercise patterns. Although they agreed that the dentist is “abnormally subjected to the ill effects of stress,” the authors believed that the stress is largely “self-inflicted,” a product of acting-out personal striving and ambition in an oc cupation in w hich the individual has considerable control over the volume and organization of practice.6
Training in effective stress reduction techniques should be a part of dentistry’s continuing education programs.
k
highest mean scores were: coping with d ifficu lt patients, trying to keep to a schedule, too much work, and unsatisfac tory auxiliary assistance. The authors also tried to relate each of the 15 items to what they considered physiologic measures of stress (blood pressure, pulse rate, and ECG readings). However, they found that only one item, “the demands of sustain ing and building a practice,” was corre lated consistently to each of their health criteria measures. It is possible to identify similarities and themes in these five studies by different authors who have used different samples, designs, and instruments. The sources of dentists’ stress are several, and they exist because of the nature of the way dentistry is practiced: a personal health service that requires the dentist to have the skilled help of other workers and the coopera tion, compliance, and trust of the patients (who are likely to be in pain or anxious about pain), while the dentist performs a physically and technically demanding procedure. Further, the service is also the basis of the dentist’s own livelihood, with an income quickly contingent on many persons and factors going right. When things go wrong, they frequently translate into time pressures, lost income, and per ceived stress.
C oo p er and o th e r s 7 fo u n d seven greatest stress in their practices. Five sources of stress emerged in their an sources of dentists’ stress hypothesized in swers: 73% named patient management a review of published studies.7 According problems, such as pressures generated by to their findings, stress was caused by patients’ fear and anxiety, late and missed poor working conditions in confined appointments, discussion of fees, and im space, with restricted work field, as ages of the dentist; 50% named business sociated with poor and fatiguing posture; management problems, such as collec routine and monotony in the dentist’s tions, dealing with insurance companies, work; lack of exercise to counteract the and coping with overhead; 38% listed sedentary nature of practice and the ten Methods strains stemming from “idealism ” and sions from coping with patients; dis the dentist’s perfectionism in the face of parities between dentists’ and society’s In the light of the sm all and necessarily tenta the daily reality of practice; 33% an expectations of the profession; the strains tive research so far produced, we decided to swered in terms of staff management, needed to produce high incom e; de explore further the sources of d entists’ stress such as interpersonal relations between mands made by the necessity to manage w ith a longer list of item s and w ith a large group of dentists at a national dental meeting. staff members and dentist; and 26% noted auxiliary staff effectively; and lack of pa We attem pted to identify specific stressors and tim e problem s, such as the tension s tients’ response and appreciation. Work to look for patterns in reported stress sources. created in the office by falling behind ing conditions and postures were dis Dentists participating in the Health Screen schedule. The authors concluded by say missed as unimportant causes by citing ing Program at the 1982 annual session of the ing that their respondents found dentistry the work of Paul8 who found little dif Am erican Dental A ssociation in Las Vegas stressful and that the methods they used to cope with their own stress were rela tively ineffective. Dunlap and Stewart4 analyzed 3,700 Three of fo u r dentists p erceiv e dentistry as m ore questionnaires from replies to a magazine poll on dentists’ stress. They found the stressful than other occupations. most common causes of practitioners’ stress to be “ . . . perfectionism, patients exhibiting pain or fear, pressure to earn more money, situations where decisions are questioned or others can’t do things right, feelings of overwork, hurry, lack of appreciation, and the feeling of being ‘in a ference in percent of British dentists re w ere asked to com plete a two-page question porting b ack ach e am ong th o se who naire on stress in dentistry. Q uestions sought dead-end job.’ ” In an earlier paper,5 we described sev worked standing and those who worked some practice characteristics but focused on eral specific behaviors of patients that are sitting down. Routine and monotony den tists’ own perceptions of various sources of both particularly bothersome to dentists were dism issed by quoting two other stress in th eir practices. R espondents were asked to rate 25 possible stressors in term s of and also frequently met in dental prac British studies910 that found only small how stressful they found each in their current tice. Such behaviors, which add stress to percentages of dentists believing their practice (not at all; a little; a fair amount; very the daily experience of practitioners, in profession dull. m uch). These appear in Table 1 and have a In a study of dentists participating at a w ide range of behaviors and factors. A lthough cluded patients’ poor oral hygiene, miss ing or being late for appointments, not California scientific meeting, Cooper and not exhaustive, the list contains items found in paying bills, and, in the chair, jerking the others11 asked 150 dentists to rate their the literature and also represents concerns perceived job pressures on a 15-item from our previous studies as w ell as the experi head away from the dentist. Howard and others6 took physiologic questionnaire. The four items with the ence of others. O’Shea-C orah—Ayer : SOURCES OF D EN TISTS' ST R E SS ■ 49
A R T IC L E S
It seems apparent that the image of dentistry as stressful is a part of dental culture.
Characteristics of respondents A total of 977 questionnaires w ere completed by A m erican dentists in active practice. Of these, 89% w ere in general practice and 11% w ere sp ecialists. V irtually a ll (97%) w ere males. M edian length of tim e in practice was approxim ately 20 years; m edian num ber of pa tien ts seen per w eek w as about 60; hours worked, about 36 per week; the m edian size of staff, including the dentists responding, was 4.5 persons. In general, these characteristics of the sam ple com pare w ell w ith the n atio n ’s dentists. However, the 1982 annual session w as held in Las Vegas and dentists from the W est w ere overrepresented, w hereas those from the N ortheast and South were u n d er represented.
Findings How do dentists perceive the stressfulness of dentistry and their ow n stress levels? Table 2 reports the answ ers to three general questions on perceived stress. Three of four dentists per ceive dentistry as more stressful than other oc cupations. Few think it is less stressful; about a fifth believe it is equally as stressful as other occupations. To gain a tim e perspective, respondents w ere also asked, “Compared w ith ten years ago, do you believe you are now working under m ore, less, or about th e sam e am o u n t of stress?” A third said they w ere currently w ork ing under more stress than ten years ago. The rest said “less stress” (39%) or “about the same am ount” (28%). W hen com paring th em selv es w ith other d entists, how ever, m ost d entists (77%) are likely to say they believe they are under m uch less or som ew hat less stress. Answers to this question on current stress w ere examined in relation to certain dentist and practice charac teristics. Being a general practitioner or a spe cialist did not seem to m atter, nor did the num ber of patients seen p er week. However, stress w as correlated w ith the length of time in practice, num ber of hours w orked per week, and size of staff: the more years in practice, the less the stress (r = -.1 5 , P < .001); the more hours w orked per week, the greater the re ported stress (r = .16, P < .001); and the more people w orking in the practice, the greater the stress perceived (r = .08, P < .02). None of these statistically significant correlations was large; it is apparent that probably several other factors are operating. Besides these general questions, the survey asked th e resp o n d en ts h o w stressfu l they found each of 25 sources of possible stress in their current practice. Table 1 presents these possible stressors arranged approxim ately in descending order of the im portance placed on them by those surveyed. The catalog of stres sors was constructed to offer a w ide range.
Although long, the list appears to identify real problems. Almost every item elicits a response from half or more of the responding dentists, indicating that it is a source of some stress. On the other hand, this list of 25 stressors contains no items that are w idely endorsed as stressful. It also appears that particular stressors vari ously affect different dentists as suggested by the distribution of answ ers to a follow-up ques tion: “W hich one of the listed stressors do you find the most stressful in your practice?” Fall ing behind schedule, patients late for or m iss ing appointm ents, and patients uncooperative in the chair w ere m ost frequently nom inated. However, virtually every item was the bete noire of some practitioner, as every item was n o m in ated by som e d en tists as the “ m ost stressful.” Table 3 presents the categorized answ ers to an open-ended question on the m ethods d en tists used to deal w ith th eir own stress. (About a fifth nam ed m ore th an one m ethod but, if more than one w as given, we coded only the first m entioned.) Doing noth in g was m en tioned by about a fourth of the dentists. Various kinds of physical activity w ere m entioned by about a third: jogging, golf, and tennis to gar d e n in g a n d e v e n in g w a lk s . F o rm s o f p s y c h o lo g ic c o p in g w e re m e n tio n e d by 13%—such m ethods as m editation and ver balizing feelings. Tim e off from the office was nam ed by 10%. Hobbies w ere m entioned by 6%. A residual category (15%) included such responses as “ a cup of decaffeinated coffee,” tranquilizer, nap, and fam ily life.
Discussion The six individual items ranked most highly seem to form a pattern: most are behaviors and working conditions that are threats to the dentist’s ability to oper ate efficien tly and effectiv ely . These prominent stresses also seem to relate particularly to patients’ needs and behav iors that are likely to occur in the operatory itself and in the daily round of work. Several are outside the dentist’s control: p atien t’s anxiety, uncooperativeness, pain threshold, and tardiness. Falling be hind schedule may result from various causes but patients’ lateness is likely to be a frequent cause. It is also obvious that many of these prom inent stresses are interconnected. For example, a stackedup waiting room creates pressure to work more quickly than is comfortable, in turn threatening ideal performance. Hurrying also leaves less time to cope with patients’ anxiety; anxiety may increase the experi ence of pain, begetting uncooperative be havior in the chair.
It is worth noting which items are at the bottom of the ranking. Although isola tion, competition, repetitiveness of work, and nonacceptance by patients of the pre ferred course of treatment are all topics of interest and advice in the popular dental literature, they are evidently secondary to other stresses. T he 25 item s were also exam ined through an exploratory factor analysis to see what dimensions in the stress sources might emerge. The aim was to reduce the 25 specific stressors to a smaller number by identifying some underlying and more general variables. This procedure not only sim p lifie s data but also m akes generalizability of results more likely. The results suggested that most of the var ious stressors fall into certain clusters, which might be interpreted as: — “Patient compliance problems,” in which the dentist is faced with patients who do not observe their side of the con tract to cooperate in their care, to follow advice, and to show up for appointments. Included are the stresses caused by pa tients’ anxiety and pain. All interfere with the practitioner’s ability to work. Far and away, this factor is the major cluster, acccounting for more than 60% of the common variance. 2 ■ Responses to three questions on stress (percentages, N = 977).______________ T a b le
“Compared with other occupations, do you believe that dentistry is more stressful, less stressful, or about the sam e?” 75 More stressful 5 Less stressful About the same 21 are under com“How much stress do you feel you ■ pared with other dentists?” 24 Much less 53 Somewhat less Somewhat more 21 2 Much more “Compared with ten years ago, do you believe you are now working under more stress, less stress, or about the sam e amount of stress?” More stress 33 39 Less stress About the same amount 28 of stress
T a b le 3 ■ F ir s t-m e n tio n e d m e th o d s u se d to d eal w ith s tre s s (p e rc e n ta g e s , N = 8 3 8 ). Nothing Physical activity Psychologic coping Tim e off Hobbies Other methods
24 32 13 10 6 15
A R T IC L E S
Stress was correlated with the length of time in practice, number of hours worked per week, and size of the staff.
't-
r
'
— “Interpersonal relations problems” of getting along with patients and staff, coping with others’ expectations, con trolling one’s own feelings, and meeting lack of appreciation; — “Physical strain of work,” long hours and too many patients; — “Econom ic pressures” of money, competition, and too few patients; — “ Outside con strain ts” by govern ment and insurance companies; and — “Perfectionism” pressures of striving for ideal dentistry and feeling responsible for patients’ oral health in the real and imperfect world. These six dimensions are not entirely independent of one another. Because this clustering is based on a single sample, one not scientifically chosen to represent all American dentists, it can only be con sidered hypothetic and needs to be vali dated in other research. Several factors, however, seem congruent with studies reviewed, and would seem to be applica ble to practicing dentists. Two other findings need comment. In Table 2, three-fourths of those surveyed think dentistry is more stressful than other occupations, but an equally high proportion believe that they are under less stress than other dentists. Perhaps this is another instance of “collective ig norance” ; individuals make one reply when reporting about a group but their aggregated individual replies present a different picture of the same group. In any case, it seems apparent that the image of dentistry as stressful is a part of dental culture. W ithin the wide agreement about dentistry’s image, however, personal ex perience also seems to have an effect, so that the answers given to the questions in Table 2 are interrelated: the more stressed the dentist currently feels, the more likely he or she is to believe things are worse than they were ten years before. The more stress he perceives currently, the more likely he or she is to see dentistry as “tougher” than other occupations. Those who perceive situations as having be come more stressful are also more likely to define dentistry itself as more stressful than other occupations. The other finding needing particular comment is the first item in Table 3, where nearly a fourth of the dentists re port that they do nothing to deal with oc
cupational stress. This is too large a group by far, even if we were to believe only half the information linking stress to a variety of chronic diseases and death. However, our data also suggest that, in influencing answers the respondents gave in regard to how stressed they felt in comparison with o th e r d e n tis ts , th e v a rio u s co p in g methods used do not differ dramatically and provide no better solution than the method of doing nothing for stress. One conclusion from the data is that training in effective stress reduction techniques should be part of dentistry’s continuing education programs. Finally, there is the caveat that this sample, although large, was drawn from volunteers attending a health screening at a national dental meeting. We would like to test these findings on a representative national sample. It would also be infor mative to gather cross-country data to discover what stresses are built into den tal care, and which are products of how dentistry is organized in our society.
nomic pressures; third-party constraints; and the strain of perfectionism and seek ing ideal results. As the well-being of the dentist and that of the staff and patients are dependent on successful management of occupational strains, this topic deserves more em piri cal study than it has so far received. We strongly suggest more studies dealing with stresses that occur daily in the im mediate environment of office, waiting room, and operatory.
___________________________ jm >A This investigation was supported, in part, by the Am erican Fund for Dental Health, Warner-Lambert Foundation, the S. S. W hite Co, and Research Grant DE 04494 from the National Institute of Dental Re search.
Dr. O’Shea is associate professor, social and pre ventive m edicine, School of M edicine, and Dr. Corah is professor, behavioral science, School of Dentistry, State University of New York at Buffalo, Farber Hall, Buffalo, NY 14214. Dr. Ayer is assistant director, be havioral research, Am erican Dental Association. Ad dress requests for reprints to Dr. Corah.
Sum m ary Almost 1,000 American dentists attend ing the 1982 Association annual meeting completed a self-administered question naire on sources of stress in dental prac tice. Most respondents identified den tistry as more stressful than other occupa tions. However, most believed that other dentists were under more stress than themselves. Dentists use a variety of ways to cope with their stress but a fourth re port they do nothing. The stressors particularly noted in cluded falling behind schedule, striving for technical perfection, causing pain or anxiety in patients, canceled or late ap pointments, and lack of cooperation from patients in the chair. However, all of the 25 listed stressors were endorsed by at least some dentists. Among the stressors lowest in the composite ratings included: isolation from fellow practitioners, com petition, monotony, lack of acceptance by patients of the preferred treatment plan, and lack of appreciation. An exploratory factor analysis leads us to hypothesize six sources in dentists’ stress: problems of patients’ compliance, pain, and anxiety; interpersonal rela tions; the physical strain of work; eco
T he authors thank A. O ’Shea, B. O’Shea, and M. Wopperer for their assistance in the conduct of this research. 1. M allinger, M .A.; Brousseau, R.R.; and Cooper, C.L. Stress and success in dentistry. J O ccup Med 20 :5 4 9 -5 5 3 ,1 9 7 8 . 2. Gift, H. Occupational hazards and emotional stress as related to morbidity and m ortality of den tists, a review of and comment on published research. Chicago, Am erican Dental Association, Bureau of Econom ic Research and Statistics, 1977. 3. Godwin, W.C., and others. Id en tification of so u rc e s o f s tre ss in p ra c tic e by re c e n t d en tal graduates. J Dent Ed 4 5 (4 ):2 2 0 -2 2 1 ,1981. 4. Dunlap, J.E., and Stewart, D. Suggestions to al leviate dental stress. Dent Econ 72:58-64, 1982. 5. Corah, N.L.; O’Shea, R.M.; and Skeels, D.K. Den tists’ perceptions of problem behaviors in patients. JADA 104(6):829-833, 1982. 6. Howard, J.H., and others. Stress in the job and career of a dentist. JADA 9 3 (3 ):6 3 0 -6 3 6 ,1976. 7. Cooper, C.L.; M allinger, M.; and Kahn, R. Den tistry: what causes it to be a stressful occupation? Int Rev Appl Psych 29:307-319, 1980. 8. Paul, E. T he elim ination of stress and fatigue in operative dentistry. Br Dent J 127:37-41, 1969. 9. Page, C.M., and Slack, G.L. A contented profes sion? A survey of Old Londoner dentists. B r Dent J 127:220-225, 1969. 10. Eccles, J.D., and Powell, M. T he health of den tists: a survey in South Wales 1965/1966. Br Dent J 123:379-387, 1967. 11. Cooper, C.L.; M allinger, M .; and Kahn, R. Iden tifying sources of occupational stress among dentists. J Occup Psychiatr 51:227-234, 1978.
O’S h ea-C orah -A yer : SOURCES OF D EN TISTS’ ST R E SS ■ 51
Six items form a pattern for stress: some are unique to dentistry, others relate to today's fastpaced society.
Sources of dentists’ stress Robert M. O’Shea, PhD N orm an L. Corah, PhD W illiam A. Ayer, DDS, PhD
r
on sid ered by the standards that A m ericans use to assess occupations, dentistry has positive qualities in abun dance, including the high prestige of a profession, and specifically of a health profession; good income; a large measure of independence; individual ownership of an enterprise; opportunity to do good for fellow human beings; participation in an applied biologic science; and consid erable control over the nature, scope, quality, and price of individual labor. These characteristics are well recognized by dentists as they regularly appear in recruitment brochures and in studies of dental school applicants, students, and practicing dentists. These benefits, however, are not abso lute. To some extent, all practitioners are a ls o r e g u la te d and in f lu e n c e d by others— by various government agencies, by insurance companies and, above all, b y th e p a t ie n t s w h o se d e n ta l, psychologic, and social needs set limits to the dentists’ latitude of action and affect the way they experience their own work. Despite all of its advantages, one of the consequences of dental practice is un doubtedly stress.1 Stress is a frequent topic of essays in the popular dental literature. It is a frequent 48 ■ JADA, Vol. 109, July 1984
T a b le 1 ■ Im p a c t o f 2 5 p o s s ib le s tre s s o r s (N = 9 7 7 ). H ow stressful? (%)
Possible stressors Falling behind schedule Striving fo r technical perfection C ausing pain in patients Anxiety in patients Patients late fo r or m issing appointm ents Patients uncooperative in chair Physical dem ands of practice Having to train new assistants Insurance com pany requirem ents G overnm ent regulation Feeling responsible fo r patient’s oral health Patients not com plying with advice Having to contain your ow n em otional reactions Having to o few patients Unrealistic patient expectations Having too m any patients Not m aking enough money Long w o rkin g hours Getting along with staff G etting along w ith patients Lack of patient appreciation Patients not a ccepting the preferred treatm ent To o m uch of sam e kind of work C om petition from other dentists Isolation from other dentists
Not at all
A little
A fair am ount
Very much
13 10 15 10 15 16 22 28 24 26
36 41 43 50 44 46 44 38 43 43
35 36 30 33 29 26 27 25 27
16 13
22
13 8 9 6 9
27 18
44 55
22 22
7 4
23 42 24 45 40 42 33 36 28
51 33 54 33 39 38 50 47 56
20
6 8 4 4 5 4 4 3
50 38 36 26
13 11 9 5
34 49 54 68
17 19 18 16 16 13 14 14
12 8
12
2 2 2 1 1
A R T IC L E S
subject at professional meetings and in continuing education courses on practice m an ag em ent. T here is also a sm all !*• amount of scientific literature that fre quently calls for more research on the sub ject. In one review, Gift2 was particularly concerned about the inadequate and con flic tin g evid en ce for various g en er alizations and folklore about dentists’ mortality, suicide, and divorce. *. Godwin and others3 asked a sample of recent graduates to identify sources of the
and psychologic measures of 33 Canadian dentists and related a number of stress symptoms to time pressures at work and also to exercise patterns. Although they agreed that the dentist is “abnormally subjected to the ill effects of stress,” the authors believed that the stress is largely “self-inflicted,” a product of acting-out personal striving and ambition in an oc cupation in w hich the individual has considerable control over the volume and organization of practice.6
Training in effective stress reduction techniques should be a part of dentistry’s continuing education programs.
k
highest mean scores were: coping with d ifficu lt patients, trying to keep to a schedule, too much work, and unsatisfac tory auxiliary assistance. The authors also tried to relate each of the 15 items to what they considered physiologic measures of stress (blood pressure, pulse rate, and ECG readings). However, they found that only one item, “the demands of sustain ing and building a practice,” was corre lated consistently to each of their health criteria measures. It is possible to identify similarities and themes in these five studies by different authors who have used different samples, designs, and instruments. The sources of dentists’ stress are several, and they exist because of the nature of the way dentistry is practiced: a personal health service that requires the dentist to have the skilled help of other workers and the coopera tion, compliance, and trust of the patients (who are likely to be in pain or anxious about pain), while the dentist performs a physically and technically demanding procedure. Further, the service is also the basis of the dentist’s own livelihood, with an income quickly contingent on many persons and factors going right. When things go wrong, they frequently translate into time pressures, lost income, and per ceived stress.
C oo p er and o th e r s 7 fo u n d seven greatest stress in their practices. Five sources of stress emerged in their an sources of dentists’ stress hypothesized in swers: 73% named patient management a review of published studies.7 According problems, such as pressures generated by to their findings, stress was caused by patients’ fear and anxiety, late and missed poor working conditions in confined appointments, discussion of fees, and im space, with restricted work field, as ages of the dentist; 50% named business sociated with poor and fatiguing posture; management problems, such as collec routine and monotony in the dentist’s tions, dealing with insurance companies, work; lack of exercise to counteract the and coping with overhead; 38% listed sedentary nature of practice and the ten Methods strains stemming from “idealism ” and sions from coping with patients; dis the dentist’s perfectionism in the face of parities between dentists’ and society’s In the light of the sm all and necessarily tenta the daily reality of practice; 33% an expectations of the profession; the strains tive research so far produced, we decided to swered in terms of staff management, needed to produce high incom e; de explore further the sources of d entists’ stress such as interpersonal relations between mands made by the necessity to manage w ith a longer list of item s and w ith a large group of dentists at a national dental meeting. staff members and dentist; and 26% noted auxiliary staff effectively; and lack of pa We attem pted to identify specific stressors and tim e problem s, such as the tension s tients’ response and appreciation. Work to look for patterns in reported stress sources. created in the office by falling behind ing conditions and postures were dis Dentists participating in the Health Screen schedule. The authors concluded by say missed as unimportant causes by citing ing Program at the 1982 annual session of the ing that their respondents found dentistry the work of Paul8 who found little dif Am erican Dental A ssociation in Las Vegas stressful and that the methods they used to cope with their own stress were rela tively ineffective. Dunlap and Stewart4 analyzed 3,700 Three of fo u r dentists p erceiv e dentistry as m ore questionnaires from replies to a magazine poll on dentists’ stress. They found the stressful than other occupations. most common causes of practitioners’ stress to be “ . . . perfectionism, patients exhibiting pain or fear, pressure to earn more money, situations where decisions are questioned or others can’t do things right, feelings of overwork, hurry, lack of appreciation, and the feeling of being ‘in a ference in percent of British dentists re w ere asked to com plete a two-page question porting b ack ach e am ong th o se who naire on stress in dentistry. Q uestions sought dead-end job.’ ” In an earlier paper,5 we described sev worked standing and those who worked some practice characteristics but focused on eral specific behaviors of patients that are sitting down. Routine and monotony den tists’ own perceptions of various sources of both particularly bothersome to dentists were dism issed by quoting two other stress in th eir practices. R espondents were asked to rate 25 possible stressors in term s of and also frequently met in dental prac British studies910 that found only small how stressful they found each in their current tice. Such behaviors, which add stress to percentages of dentists believing their practice (not at all; a little; a fair amount; very the daily experience of practitioners, in profession dull. m uch). These appear in Table 1 and have a In a study of dentists participating at a w ide range of behaviors and factors. A lthough cluded patients’ poor oral hygiene, miss ing or being late for appointments, not California scientific meeting, Cooper and not exhaustive, the list contains items found in paying bills, and, in the chair, jerking the others11 asked 150 dentists to rate their the literature and also represents concerns perceived job pressures on a 15-item from our previous studies as w ell as the experi head away from the dentist. Howard and others6 took physiologic questionnaire. The four items with the ence of others. O’Shea-C orah—Ayer : SOURCES OF D EN TISTS' ST R E SS ■ 49
A R T IC L E S
It seems apparent that the image of dentistry as stressful is a part of dental culture.
Characteristics of respondents A total of 977 questionnaires w ere completed by A m erican dentists in active practice. Of these, 89% w ere in general practice and 11% w ere sp ecialists. V irtually a ll (97%) w ere males. M edian length of tim e in practice was approxim ately 20 years; m edian num ber of pa tien ts seen per w eek w as about 60; hours worked, about 36 per week; the m edian size of staff, including the dentists responding, was 4.5 persons. In general, these characteristics of the sam ple com pare w ell w ith the n atio n ’s dentists. However, the 1982 annual session w as held in Las Vegas and dentists from the W est w ere overrepresented, w hereas those from the N ortheast and South were u n d er represented.
Findings How do dentists perceive the stressfulness of dentistry and their ow n stress levels? Table 2 reports the answ ers to three general questions on perceived stress. Three of four dentists per ceive dentistry as more stressful than other oc cupations. Few think it is less stressful; about a fifth believe it is equally as stressful as other occupations. To gain a tim e perspective, respondents w ere also asked, “Compared w ith ten years ago, do you believe you are now working under m ore, less, or about th e sam e am o u n t of stress?” A third said they w ere currently w ork ing under more stress than ten years ago. The rest said “less stress” (39%) or “about the same am ount” (28%). W hen com paring th em selv es w ith other d entists, how ever, m ost d entists (77%) are likely to say they believe they are under m uch less or som ew hat less stress. Answers to this question on current stress w ere examined in relation to certain dentist and practice charac teristics. Being a general practitioner or a spe cialist did not seem to m atter, nor did the num ber of patients seen p er week. However, stress w as correlated w ith the length of time in practice, num ber of hours w orked per week, and size of staff: the more years in practice, the less the stress (r = -.1 5 , P < .001); the more hours w orked per week, the greater the re ported stress (r = .16, P < .001); and the more people w orking in the practice, the greater the stress perceived (r = .08, P < .02). None of these statistically significant correlations was large; it is apparent that probably several other factors are operating. Besides these general questions, the survey asked th e resp o n d en ts h o w stressfu l they found each of 25 sources of possible stress in their current practice. Table 1 presents these possible stressors arranged approxim ately in descending order of the im portance placed on them by those surveyed. The catalog of stres sors was constructed to offer a w ide range.
Although long, the list appears to identify real problems. Almost every item elicits a response from half or more of the responding dentists, indicating that it is a source of some stress. On the other hand, this list of 25 stressors contains no items that are w idely endorsed as stressful. It also appears that particular stressors vari ously affect different dentists as suggested by the distribution of answ ers to a follow-up ques tion: “W hich one of the listed stressors do you find the most stressful in your practice?” Fall ing behind schedule, patients late for or m iss ing appointm ents, and patients uncooperative in the chair w ere m ost frequently nom inated. However, virtually every item was the bete noire of some practitioner, as every item was n o m in ated by som e d en tists as the “ m ost stressful.” Table 3 presents the categorized answ ers to an open-ended question on the m ethods d en tists used to deal w ith th eir own stress. (About a fifth nam ed m ore th an one m ethod but, if more than one w as given, we coded only the first m entioned.) Doing noth in g was m en tioned by about a fourth of the dentists. Various kinds of physical activity w ere m entioned by about a third: jogging, golf, and tennis to gar d e n in g a n d e v e n in g w a lk s . F o rm s o f p s y c h o lo g ic c o p in g w e re m e n tio n e d by 13%—such m ethods as m editation and ver balizing feelings. Tim e off from the office was nam ed by 10%. Hobbies w ere m entioned by 6%. A residual category (15%) included such responses as “ a cup of decaffeinated coffee,” tranquilizer, nap, and fam ily life.
Discussion The six individual items ranked most highly seem to form a pattern: most are behaviors and working conditions that are threats to the dentist’s ability to oper ate efficien tly and effectiv ely . These prominent stresses also seem to relate particularly to patients’ needs and behav iors that are likely to occur in the operatory itself and in the daily round of work. Several are outside the dentist’s control: p atien t’s anxiety, uncooperativeness, pain threshold, and tardiness. Falling be hind schedule may result from various causes but patients’ lateness is likely to be a frequent cause. It is also obvious that many of these prom inent stresses are interconnected. For example, a stackedup waiting room creates pressure to work more quickly than is comfortable, in turn threatening ideal performance. Hurrying also leaves less time to cope with patients’ anxiety; anxiety may increase the experi ence of pain, begetting uncooperative be havior in the chair.
It is worth noting which items are at the bottom of the ranking. Although isola tion, competition, repetitiveness of work, and nonacceptance by patients of the pre ferred course of treatment are all topics of interest and advice in the popular dental literature, they are evidently secondary to other stresses. T he 25 item s were also exam ined through an exploratory factor analysis to see what dimensions in the stress sources might emerge. The aim was to reduce the 25 specific stressors to a smaller number by identifying some underlying and more general variables. This procedure not only sim p lifie s data but also m akes generalizability of results more likely. The results suggested that most of the var ious stressors fall into certain clusters, which might be interpreted as: — “Patient compliance problems,” in which the dentist is faced with patients who do not observe their side of the con tract to cooperate in their care, to follow advice, and to show up for appointments. Included are the stresses caused by pa tients’ anxiety and pain. All interfere with the practitioner’s ability to work. Far and away, this factor is the major cluster, acccounting for more than 60% of the common variance. 2 ■ Responses to three questions on stress (percentages, N = 977).______________ T a b le
“Compared with other occupations, do you believe that dentistry is more stressful, less stressful, or about the sam e?” 75 More stressful 5 Less stressful About the same 21 are under com“How much stress do you feel you ■ pared with other dentists?” 24 Much less 53 Somewhat less Somewhat more 21 2 Much more “Compared with ten years ago, do you believe you are now working under more stress, less stress, or about the sam e amount of stress?” More stress 33 39 Less stress About the same amount 28 of stress
T a b le 3 ■ F ir s t-m e n tio n e d m e th o d s u se d to d eal w ith s tre s s (p e rc e n ta g e s , N = 8 3 8 ). Nothing Physical activity Psychologic coping Tim e off Hobbies Other methods
24 32 13 10 6 15
A R T IC L E S
Stress was correlated with the length of time in practice, number of hours worked per week, and size of the staff.
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— “Interpersonal relations problems” of getting along with patients and staff, coping with others’ expectations, con trolling one’s own feelings, and meeting lack of appreciation; — “Physical strain of work,” long hours and too many patients; — “Econom ic pressures” of money, competition, and too few patients; — “ Outside con strain ts” by govern ment and insurance companies; and — “Perfectionism” pressures of striving for ideal dentistry and feeling responsible for patients’ oral health in the real and imperfect world. These six dimensions are not entirely independent of one another. Because this clustering is based on a single sample, one not scientifically chosen to represent all American dentists, it can only be con sidered hypothetic and needs to be vali dated in other research. Several factors, however, seem congruent with studies reviewed, and would seem to be applica ble to practicing dentists. Two other findings need comment. In Table 2, three-fourths of those surveyed think dentistry is more stressful than other occupations, but an equally high proportion believe that they are under less stress than other dentists. Perhaps this is another instance of “collective ig norance” ; individuals make one reply when reporting about a group but their aggregated individual replies present a different picture of the same group. In any case, it seems apparent that the image of dentistry as stressful is a part of dental culture. W ithin the wide agreement about dentistry’s image, however, personal ex perience also seems to have an effect, so that the answers given to the questions in Table 2 are interrelated: the more stressed the dentist currently feels, the more likely he or she is to believe things are worse than they were ten years before. The more stress he perceives currently, the more likely he or she is to see dentistry as “tougher” than other occupations. Those who perceive situations as having be come more stressful are also more likely to define dentistry itself as more stressful than other occupations. The other finding needing particular comment is the first item in Table 3, where nearly a fourth of the dentists re port that they do nothing to deal with oc
cupational stress. This is too large a group by far, even if we were to believe only half the information linking stress to a variety of chronic diseases and death. However, our data also suggest that, in influencing answers the respondents gave in regard to how stressed they felt in comparison with o th e r d e n tis ts , th e v a rio u s co p in g methods used do not differ dramatically and provide no better solution than the method of doing nothing for stress. One conclusion from the data is that training in effective stress reduction techniques should be part of dentistry’s continuing education programs. Finally, there is the caveat that this sample, although large, was drawn from volunteers attending a health screening at a national dental meeting. We would like to test these findings on a representative national sample. It would also be infor mative to gather cross-country data to discover what stresses are built into den tal care, and which are products of how dentistry is organized in our society.
nomic pressures; third-party constraints; and the strain of perfectionism and seek ing ideal results. As the well-being of the dentist and that of the staff and patients are dependent on successful management of occupational strains, this topic deserves more em piri cal study than it has so far received. We strongly suggest more studies dealing with stresses that occur daily in the im mediate environment of office, waiting room, and operatory.
___________________________ jm >A This investigation was supported, in part, by the Am erican Fund for Dental Health, Warner-Lambert Foundation, the S. S. W hite Co, and Research Grant DE 04494 from the National Institute of Dental Re search.
Dr. O’Shea is associate professor, social and pre ventive m edicine, School of M edicine, and Dr. Corah is professor, behavioral science, School of Dentistry, State University of New York at Buffalo, Farber Hall, Buffalo, NY 14214. Dr. Ayer is assistant director, be havioral research, Am erican Dental Association. Ad dress requests for reprints to Dr. Corah.
Sum m ary Almost 1,000 American dentists attend ing the 1982 Association annual meeting completed a self-administered question naire on sources of stress in dental prac tice. Most respondents identified den tistry as more stressful than other occupa tions. However, most believed that other dentists were under more stress than themselves. Dentists use a variety of ways to cope with their stress but a fourth re port they do nothing. The stressors particularly noted in cluded falling behind schedule, striving for technical perfection, causing pain or anxiety in patients, canceled or late ap pointments, and lack of cooperation from patients in the chair. However, all of the 25 listed stressors were endorsed by at least some dentists. Among the stressors lowest in the composite ratings included: isolation from fellow practitioners, com petition, monotony, lack of acceptance by patients of the preferred treatment plan, and lack of appreciation. An exploratory factor analysis leads us to hypothesize six sources in dentists’ stress: problems of patients’ compliance, pain, and anxiety; interpersonal rela tions; the physical strain of work; eco
T he authors thank A. O ’Shea, B. O’Shea, and M. Wopperer for their assistance in the conduct of this research. 1. M allinger, M .A.; Brousseau, R.R.; and Cooper, C.L. Stress and success in dentistry. J O ccup Med 20 :5 4 9 -5 5 3 ,1 9 7 8 . 2. Gift, H. Occupational hazards and emotional stress as related to morbidity and m ortality of den tists, a review of and comment on published research. Chicago, Am erican Dental Association, Bureau of Econom ic Research and Statistics, 1977. 3. Godwin, W.C., and others. Id en tification of so u rc e s o f s tre ss in p ra c tic e by re c e n t d en tal graduates. J Dent Ed 4 5 (4 ):2 2 0 -2 2 1 ,1981. 4. Dunlap, J.E., and Stewart, D. Suggestions to al leviate dental stress. Dent Econ 72:58-64, 1982. 5. Corah, N.L.; O’Shea, R.M.; and Skeels, D.K. Den tists’ perceptions of problem behaviors in patients. JADA 104(6):829-833, 1982. 6. Howard, J.H., and others. Stress in the job and career of a dentist. JADA 9 3 (3 ):6 3 0 -6 3 6 ,1976. 7. Cooper, C.L.; M allinger, M.; and Kahn, R. Den tistry: what causes it to be a stressful occupation? Int Rev Appl Psych 29:307-319, 1980. 8. Paul, E. T he elim ination of stress and fatigue in operative dentistry. Br Dent J 127:37-41, 1969. 9. Page, C.M., and Slack, G.L. A contented profes sion? A survey of Old Londoner dentists. B r Dent J 127:220-225, 1969. 10. Eccles, J.D., and Powell, M. T he health of den tists: a survey in South Wales 1965/1966. Br Dent J 123:379-387, 1967. 11. Cooper, C.L.; M allinger, M .; and Kahn, R. Iden tifying sources of occupational stress among dentists. J Occup Psychiatr 51:227-234, 1978.
O’S h ea-C orah -A yer : SOURCES OF D EN TISTS’ ST R E SS ■ 51