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Stress in the job and career of a dentist
A total of 33 Canadian dentists participated in a study to examine job stress and other issues relating to their careers in dentistry. The results confirm ed previous assumptions that stress is largely self-inflicted, and that physical exercise and job satisfaction are greatly related to stress.
Stress in the job and career of a dentist
John H. Howard, DBA D. A. Cunningham, PhD Peter A. Rechnitzer, MD, London, Ontario, Canada R. C. Goode, PhD, Toronto
D entists m ay, indeed, be abnorm ally subjected to the ill effects o f stress. T he jo b of a dentist is physically hard; m oreover, the m ajority of den tists, because they are private practitioners, are involved with the long-term strains of building a successful practice. C entral to the day-to-day running of a dental practice is the m anagem ent o f time. High de m ands for service and the need to see enough patients to ensure financial success mean that each day is fully scheduled. Patients who miss appointm ents, those who need em ergency trea t m ent, and com plications constantly cause chang es in schedules and result in increased time pressure problem s even in the best-planned day. O nce the schedule has been upset, the pressure is com pounded as patients becom e irritable be cause of unexpected waiting and as the staff re act to the need to replan and adjust. T he dentist, him self, is often confronted with choosing be tw een the quality of his work and the goodwill of his patients. T he ability to cope with these and other stressinducing factors in dentistry does, of course, 630 ■ JADA, Vol. 93, Septem ber 1976
vary with individual circum stances. The den tist’s personality and experience and the organ ization of his practice are exam ples of variables that m ay influence o r m oderate the effects of the jo b ’s pressure.
R esearch study
T hirty-three practicing C anadian dentists took part in a study designed to examine job stress and other issues related to their careers in den tistry. T he twofold objective of the study was to trace the sources and patterns of stress in the job and to determ ine w hether personal factors such as o n e’s physical condition affect the dentist's ability to cope with the tensions of his career. T he participants w ere attending a voluntary dental fitness clinic at the time of the study. D ata were collected concerning the individual’s job, career, and physical condition. Each participant was interview ed and, in addition, com pleted a questionnaire designed from a previous pilot study, to solicit inform ation about his practice, his career, and his feelings about the job. C er tain physiologic variables that are known to be indicative o f an individual’s health also were m easured. T he analysis sought to determ ine trends, patterns, and relationships, with the in tent of isolating the im portant connections be tw een work, stress, and health. The character
Table 1 ■ S c h e d u le b e h av io r and w o rk patterns. Averages In dealing with my dayto-day business I am always ahead I can usually keep ahead of my patients I occasionally fall behind I am continually unable to keep ahead of the clock No answer
N 1
%
Yr in A ge (yr) practice
0.03
29
5
Hr/day
Evenings/month
8.0
0
Lunch time (min) 60
Income ($) 25,000
11
0.33
39
14
8.9
0.73
63
30,600
1 0
0.30
34
8
8.9
1.3
58
29,400
10
0.30 0.03
40
14
9.1
1.9
43
36,200
1
istics of age and the w ork experience of the group w ere as follows: m edian age was 35 years; minimum, 29 years, m axim um , 54 years; median w ork experience was 10 years; minimum, 1 year; maxim um, 28 years.
Work patterns and career history A s part o f the study, the dentists provided infor m ation about the establishm ent of their prac tices, their subsequent mobility, their patients, and their working habits. W hen they started their careers, 46% of the dentists had chosen their location on the basis o f a desire to live in a particular com m unity rath e r than on the advice o f an outside party. Sixty percent had started in private practice rather than in association with other new or established den tists or in clinics. H elp in starting their practice had been derived in m ost instances from other dentists; 60% of the participating dentists indi cated th at they had received the m ost help from this source rath er than from other graduates or the dental school. Finances needed to start the practice had generally not been a problem: 12% found financing extrem ely easy, 42% found it relatively easy, 27% had some difficulty, and only 12% had considerable difficulty. Once the dentists had started in practice their rate o f mobility had been low, with 70% o f the dentists having w orked in only one com munity since graduation from dental school, and 85% in either one or tw o com m unities. Seventy-five percent o f the group had worked in only one or two offices since graduation and 90% in either one, tw o, or three offices. Expected future mobility was similarly low. Only 3% said th at they would be happy to m ove, com pared with 39% who would not mind moving and 58% who indicated an unwillingness to move. T h e difficulty in establishing a clientele in a new location could easily account for this atti tude. Regarding the organization o f their practice, 51% of the group em ployed only one assistant of
any kind and 78% em ployed one or tw o assis tants. T he average working day was 8.9 hours, with a range from 6.3 to 10.7 hours. T he average am ount of time taken for lunch was 55 minutes and ranged from 0 to 90 m inutes. T he num ber of evenings p er m onth that the participants worked ranged from zero to eight, with an average of ap proxim ately one. Forty-five percent o f the d en tists’ patients w ere adults, 25% w ere teenagers, and 24% were children. A pattern em erges, therefore, of the typical m em ber of the sam ple group. H e is m ale, in his mid-30s. H e chose his location on the basis of his desire to live in a particular com m unity and is reluctant to relocate once established. H e had little financial difficulty in getting established, and now works about a nine-hour day. It is also known that the m ajority of the participants were in a general rather than a specialized practice. T he selection of the sam ple was not controlled since it was made up of those dentists attending a voluntary clinic. T here is no evidence, how ever, to suggest that the sam ple would not be representative of C anadian dentists. In an un published work by C unningham , the dentists studied w ere com pared with a general popula tion of working men and no significant differ ences in physical fitness w ere found.
Work, health, and physical condition It has already been noted that the tim e-pressure problem is a fundam ental source o f stress in the dentist’s job. It is not surprising, therefore, to find that m any o f the dentists reported patient scheduling as a m ajor source o f tension and irri tation. Participants w ere asked to state w hether they tend to be ahead of or behind schedule, and the responses to this question w ere cross-referenced against the average values of age, exper ience, the num ber o f hours w orked p er day, the num ber of evenings w orked p er m onth, the am ount o f tim e taken fo r lunch, and income. Several inferences can be draw n from Table 1. Howard—others: STRESS IN JOB AND CAREER ■ 631
Table 2 ■ Schedule behavior, physical work capacity, and stress symptoms. Averages In dealing with my day-to-day business am alw ays ahead of sch edule 1 can usually keep ahead of my patients 1 occasion ally fall behind sch edu le 1 am continually unable to keep ahead of the clock No answer
N
Physical work capacity
S tress sym ptoms
1
1,240
7.0
11
1,134
1.9
10
983
3.8
927
4.3
1
9 2
Table 3 ■ Exercise behavior as re vealed in answers to the question, “ Do you make a specific attempt to get a minimum amount of exercise?” and physical work capacity (PWC). Answer
N
Av PWC
Yes No
18
1,161 846
12
O f the dentists, 60% are occasionally or contin ually behind schedule com pared with only 36% who are usually or always ahead of schedule. Indeed, only one individual reported being al w ays ahead o f schedule. N o t surprisingly, those dentists who tend to be behind schedule work longer hours, w ork m ore evenings, and take less tim e for lunch. A s a consequence, they also have higher incom es. T here is no consistent relation ship betw een age or experience and the ability to rem ain on schedule. T able 2 gives the relationship betw een the abil ity to keep on schedule and m easures of physical condition and o f stress sym ptom s. Physical work capacity was determ ined in this study by having the dentist ride a bicycle ergom eter. T he figures quoted are m easurem ents of the rate of work produced at a constant heart rate o f 170 beats p er m inute (physical w ork capacity 170) and are a good m easure o f the individual’s physical con dition o r cardiovascular fitness. T he stress indi cato r is a simple total of the stress sym ptom s re ported from a checklist of 40 such sym ptom s given in the questionnaire. This sym ptom check list is a com posite list constructed with reference to our previous research on stress sym ptom s. In previous work by us, the list had been used as an effective indicator of stress by both the simple addition of th e num ber of stress sym ptom s re ported and by the identification o f five health factors, using factor-analytic techniques. In this research , a simple addition of the num ber of stress sym ptom s reported was used as an indi cato r o f stress levels. Both indicators—physical w ork capacity and 632 ■ JADA, Vol. 93, September 1976
stress sym ptom s— show a consistent trend with the problem s of patient scheduling. T hose par ticipants w ho are always or usually ahead of schedule have a higher physical work capacity than those who tend to be behind schedule. In addition, increasing stress sym ptoms are asso ciated with the increasing tendency to fall behind schedule. N o t m uch significance, of course, can be attached to the high stress sym ptom s report ed by the single individual who was always ahead of schedule. Along with the findings given in Table 1 (that falling behind schedule leads to longer working hours, shorter lunches, and working m ore even ings), a fuller picture begins to emerge though it is not yet possible to speculate on which are the causes and which the effects. A m ultiple regression analysis was run on the results to determ ine the variables that are m ost strongly correlated with being ahead o f or be hind schedule. Age and experience w ere found to be rela tively poor predictors o f a dentist’s schedule be havior though the trends w ere, as would be ex pected, that younger dentists tend to be ahead of schedule and that experienced dentists also tend to be ahead o f schedule. T he implied contradic tion here probably explains the low correlation. B etter predictors w ere the am ount of tim e taken for lunch and the num ber of assistants em ployed. T he strongest correlation with being ahead of schedule was with physical w ork capacity. Though regression analysis does not establish a causal relationship, it is reasonable to suggest that the individual’s physical condition is at least partially responsible for schedule problem s. This is a highly significant finding and suggests that the best predictor of a dentist’s productivity may be his physical fitness.
Physical work capacity and exercise Since the dentist’s jo b is relatively active, we m ust be cautious o f using the generalization of the relationship betw een one’s physical condi tion and work perform ance with regard to other occupations. It is widely know n, how ever, that exercise is an effective m eans of reducing ten sions and irritation, and in addition, Table 3 shows that there is a significant relationship be tw een exercise and physical work capacity. Thus, for dentists, exercise not only helps w ork off the tensions o f the job but gives a secon-
Table 4 ■ Exercise behavior as revealed in answers to the ques tion, "Do you m a k e a specific attempt to get a minimum amount of exercise?” and stress symptoms. Answer
N
Yes No
18
Av. no. stress symptoms 2.25 4.90
12
Table 5 ■ Age and physical work capacity (PWC). Age (yr)
N
Av PWC
20-30 31-34 35-42 >42
7
1,044 906 994 1,163
8
9 8
dary payoff by im proving o n e’s physical condi tion and thereby his ability to cope with jo b pres sures as they occur. This relationship is con firm ed by relating stress sym ptom s to exercise (Table 4). T hose participants who attem pt to ex ercise suffer few er than half the stress sym ptoms reported by th e nonexercisers. T able 5 shows how the dentists’ physical con dition varies with age. It is interesting to note a decline in the average physical w ork capacity of the participants who are in the m iddle age range from 31 to 42 years followed by a rise after age 42. Table 6 gives som e illumination of this obser vation by including the effect o f exercise. In each age bracket, those who m ade an at tem pt to get at least a minimum am ount of exer cise showed a significantly higher physical work capacity. Only the 35- to 42-year-old age bracket contained few er nonexercisers than exercisers. O f those in the 31- to 42-year-old age bracket, 52% w ere exercisers com pared with an overall average o f 60%. T here is no ready explanation for the high w ork capacity of the older partici pants, though sampling bias might be expected since the group was participating in a program in which physical exercise was to be em phasized. It is possible that the older participants in the program w ould have had a particular interest in their physical condition before choosing to at tend the clinic. The age-related changes in exercise habits also could conceivably be associated with stag es in the participant’s career and in the devel opm ent of his practice. In the early stages, the dentist tends to retain both the fitness and the exercise habits established during his college career. With time, the growth of his practice, perhaps o f his family and his role in the commun-
Table 6 ■ Age, exercise, and physical work capacity (PWC). Exercise in PWC Age group (yr)
Y es (N)
No (N)
20-30 31-34
1,299 (4) 1,026 (6 )
692 (2) 545 (2)
35-42 >42
995 (3) 1,264 (6 )
993 (6 ) 860 (2 )
% exercisers 66 7 5
33 75
\ z
52
ity all im pose conflicting tim e dem ands th at pro gressively break down exercise habits and im pair o n e’s physical condition. W hen in his 40s, with an established practice and a growing fam ily, the tim e-pressure problem becom es less sev ere for the dentist. T he reaw akened interest in exercise and physical condition also may be as sociated with the general psychological phenom enon known as the “ male m enopause” or mid life crises.
Work and stress T h e foregoing relationships can be integrated into a chain of events as speculated in F igure 1. Beginning at the left o f the diagram, we see the dentist overloaded with patients. This assertion is derived from the high correlation betw een in com e and the tendency to fall behind schedule which, given the relatively uniform fee scales, implies that m ore patients are being scheduled per day or that few er assistants are being em ployed or both. T he consequent tim e-pressure problem leads to shorter lunches, m ore evening w ork, and longer working days. This self-inflicted pressure is likely to be prom pted by the dem ands o f a growing practice, which are dependent on the stage of the dentist’s career, and by certain qualities of personality or character. T he participants in this study w ere classified by the Friedm an and R osenm an1 clas sification as to w hether they w ere type A or B persons. T hese authors describe the behavior pattern for type A persons as: An overt behaviour syndrome or style o f living char acterized by excesses of com petitiveness, striving for achievement, aggressiveness (sometimes strin gently repressed), time urgency, acceleration o f com mon activities, restlessness, hostility, hyper alertness, explosiveness of speech amplitude, tenseness o f facial musculature and feelings o f struggle against the lim itations o f time and the insensitivity o f the environ ment. This torrent of life is usually, but not always, channeled into a vocation or profession with such dedication that Type A persons often neglect other aspects of their life, such as family and recreation. Howard—others: STRESS IN JOB AND CAREER ■ 633
Table 7 ■ Satisfaction as revealed in answers to the question, “How strongly do you feel it would benefit you to change jobs or type of work activity?” and physical work capacity (PWC) and stress symptoms. Av PW C
Av stress sy m p to m s
6 6
1,211 1,029
5.0 2.2
18
991
3.3
N S tro n g ly (u s u a lly d is s a tis fie d d en tist) M o d e ra te ly N o t at all (u s u a lly sa tis fie d d e n tist)
T y p e B people, in contrast, are m ore relaxed, m ore easy going. They are seldom im patient and take m ore tim e to enjoy avocational pursuits. T hey w ork steadily, seldom lack tim e, and are not easily irritated. T h ere w ere ten type A and 22 type B persons in th e study. O f the type A persons, 80% indi cated they w ere occasionally or continuously be hind schedule. O f the type B persons, only 50% reported being occasionally or continously be hind schedule. Adding in the effects of exercise and physical condition to self-inflicted pressure, the diagram takes on a disturbing circularity. F irst, the pres sures of the work situation leave little tim e o r en ergy for recreational exercise. This has a prim ary effect on stress sym ptom s, which are not now w orked off, and a secondary effect on physical work capacity that steadily declines and leads to still p o o rer ability to keep to schedule. T h e behavior seen in Figure 1 of the dentist striving to build his practice at the expense of personal physical condition and exercise can probably be seen in other occupations. This would be particularly true o f professions and o ther careers in which the individual has exten sive control over his personal work load. F igure 1 shows the role of individual charac teristics and environm ent and traces the effects through the stress experienced. B ehavior result ing in stress also may be related to w ork and car eer satisfaction.
W o rk and c aree r satisfactio n
Job satisfaction was estim ated by the partici p a n t’s response to the question: H ow strongly do you feel it would benefit you to change jobs or your type of work activity? Table 7 gives the average physical work capacity and total stress sym ptom s for each level of satisfaction. Som ew hat unexpectedly, high physical w ork capacity is found to be associated with a high level o f dissatisfaction, and the trend o f stress 634 ■ JADA, Vol. 93, September 1976
sym ptom s with satisfaction is not consistent. It is possible that stress sym ptom s may be related m ore to jo b dissatisfaction than to exercise. A recent 15-year longitudinal study showed that jo b and career satisfaction are highly related to health and are the best predictors o f longevity.2 It was thought that satisfaction may be related to the num ber of years in practice, o n e’s physi cal condition, the feeling o f patient appreciation of o n e’s w ork, the length o f time spent in o n e’s present location, one’s perception of his work load, o n e’s feelings that the job interferes with his personal life, and the incidence o f stress sym ptoms. T he relative effects o f these factors w ere m ea sured by regression analysis. This show ed the best predictors of jo b satisfaction to be the jo b ’s interference with one’s personal life, the length of tim e in one’s present location, and the num ber of years o f experience o f the dentist. T h at is, a lack of satisfaction in one’s job results from the feeling that the jo b interferes with one’s person al life, that one has spent too long a time in the sam e location, and from a limited work exper ience. T he less highly correlated but also signifi cant factors of feelings of a lack of patient appre ciation, a w ork load that is not perceived as heavy, and high stress sym ptom s are associated with a low level in jo b satisfaction. By combining these factors, we w ere able to build a com posite picture o f the dissatisfied den tist. L ack of w ork experience implies th at a young dentist is m ore likely to be dissatisfied. This is consistent both with a high level of physical w ork capacity and with feelings of a lack o f patient ap preciation. T he absence of patient appreciation probably affects dentists o f all ages, but the dis crepancy betw een perceived appreciation and expectations o f appreciation is likely to be great er for the younger man. Since a dentist spends a relatively long period o f time in one location, it is likely that the dissatisfied dentist m oved to his present location after graduation and stayed there. A feeling that o ne’s work load is low seems to conflict with the feelings that one’s w ork load is a great interference with one’s personal life. G iven the inexperience of the dissatisfied den tist, it is probable that his com plaint of a low w ork load is really an expression of dissatisfaction with the size o f his developing practice. Job satisfaction provides a further elem ent that can be added to the m echanism outlined in Figure 1. T he im pact of job satisfaction is direct ly related to the stress created by the tim e-pres sure problem and the low exercise cycle. W e hy-
FATIGUES
MORE
EASILY
'Type A' C h a r a c t e r
Non-Exerciser More
Overloads Self Wit h P a t i e n t s
Evenings/Month T e n d s To Be ►Behind Schedili e
T a k e s Less ► T i m e For — L un ch
T i me
I
No T i m e Fo r Exercise
Pressure To o T i r e d to Be I n t e r e s t e d i
More Hours/Day
Reduced Ph ys ical *Work C a p a c i ty
More Patients/Day C a reer Phase (Building Practice)
1
High Salary
■ . Uses Fewer As si st ant s
Higher S t re ss Symptoms
Not W o r k i n g ’Of f T e n s i o n Reduced Capacity To« C o p e Wi t h S t r e s s
Fig 1 • In te rp re ta tio n o f re la tio n s h ip s b e tw e e n w o rk p a tte rn s , tim e -p re s s u re p ro b le m s , e x e rc is e b e h a v io r, a nd s tre s s sym p to m s .
Fig 2 ■ In te rp re ta tio n o f a d d itio n a l in flu e n c e o f w o rk s a tis fa c tio n .
p othesize that the stress produced by the den tist’s jo b can be attenuated if the dentist derives a high level of satisfaction from his work. This is shown in Figure 2. Except that both a low level of satisfaction and work overload are associated with the early, building phase of his career, the determ inants of job satisfaction are o th er than the tim e-pressurestress cycle. Job satisfaction, therefore, may or may not be experienced in com bination with the self-inflicted overload behavior.
C o nclusions In recent years, concern about stress has become an alm ost universal topic. Its detrim ental effects on health and longevity are recognized by people associated with the medical and scientific pro fessions as well as by those who are not. P artic
ularly for men, the principal sources of stress are to be found in the area of jo b and career. This is so since it is through his work that the individual establishes and m aintains his identity and selfimage. D ifferent occupations obviously have differ ent potentials for inducing stress. Studies have show n that even specialization within an occu pation can be o f considerable consequence in term s o f m orbidity and mortality. A study by R us sell3 showed that in each of three different pro fessions— m edicine, dentistry, and law—general ists as opposed to specialists had a higher inci dence o f coronary heart disease. Am ong these professions, there is strong evidence that den tists are especially prone to the effects of high stress. C anadian statistics show that the longev ity of dentists is low er than that for the average white, m ale, working population. A fuller under standing of the m echanism of stress production H ow ard— others: STRESS IN JOB AND CAREER ■ 635
can only com e through an integration of the na ture o f the occupation with the character and be havior o f the individual. This is particularly true in occupations such as dentistry w here there is considerable range in which the individual can control the volum e and organization of his own work. In such a jo b , it seems that stress is often large ly self-inflicted; it is the result of acting out, in the jo b and career, th e psychological forces of long ing and striving. Stress is one of the risks o f great am bition. This investigation tends to confirm all of these assum ptions. In addition, though, it has provid ed encouraging evidence that the effects o f stress can be m itigated. Specifically, it has shown the beneficial effect o f tw o factors. F irst, physical exercise has been found to be an effective m eans o f reducing tension and improving the capacity to cope with the dem ands o f the job. Second, notw ithstanding the dem anding nature of his
636 ■ JADA, Vol. 93, Septem ber 1976
w ork, it is possible for a dentist to experience a high degree o f jo b satisfaction. This satisfaction can be an im portant contributory factor to good health.
T h e a u th o rs th a n k J. D an ie ls, W. J. D u n n , D. E v e ritt, M. H agerm an, D. N ic h o ls o n , T. P a la n d i, M. T h o m a s , a n d L. V la c h fo r th e ir a s s is ta n c e in th e c o lle c tio n o f d a ta and fo r p ro v id in g co m m e n ts a n d su g g e s tio n s . Drs. H o w a rd , C u n n in g h a m , and R e c h n itz e r a re fro m th e U n i v e rs ity o f W estern O n ta rio , L o n d o n , O n ta rio , C anada. Dr. G o o d e is fro m th e U n iv e rs ity o f T o ro n to . A d d re s s re q u e s ts Tor re p rin ts to Dr. H o w a rd , S c h o o l o f B u s in e s s A d m in is tra tio n , th e U n iv e rs ity o f W e ste rn O n ta rio , L o n d o n , O n ta rio , C anada.
1. F rie d m a n , M., and R ose n m a n, R.H. T y p e A b e h a v io r and y o u r hea rt. N ew Y o rk , A lfre d A. K n o p f, 1974, p 67. 2. P a lm o re , E.B. P h y s ic a l, m e n ta l, and s o c ia l fa c to rs in p re d ic t in g lo n g e v ity . G e ro n to lo g is t 9:103 S u m m e r 1969. 3. R ussek, H.l. E m o tio n a l s tre s s and c o ro n a ry h e a rt disease in A m e ric a n p h y s ic ia n s , d e n tis ts and law ye rs. A m J M ed Sei 243: 716 J u n e 1962.
Stress in the job and career of a dentist
John H. Howard, DBA D. A. Cunningham, PhD Peter A. Rechnitzer, MD, London, Ontario, Canada R. C. Goode, PhD, Toronto
D entists m ay, indeed, be abnorm ally subjected to the ill effects o f stress. T he jo b of a dentist is physically hard; m oreover, the m ajority of den tists, because they are private practitioners, are involved with the long-term strains of building a successful practice. C entral to the day-to-day running of a dental practice is the m anagem ent o f time. High de m ands for service and the need to see enough patients to ensure financial success mean that each day is fully scheduled. Patients who miss appointm ents, those who need em ergency trea t m ent, and com plications constantly cause chang es in schedules and result in increased time pressure problem s even in the best-planned day. O nce the schedule has been upset, the pressure is com pounded as patients becom e irritable be cause of unexpected waiting and as the staff re act to the need to replan and adjust. T he dentist, him self, is often confronted with choosing be tw een the quality of his work and the goodwill of his patients. T he ability to cope with these and other stressinducing factors in dentistry does, of course, 630 ■ JADA, Vol. 93, Septem ber 1976
vary with individual circum stances. The den tist’s personality and experience and the organ ization of his practice are exam ples of variables that m ay influence o r m oderate the effects of the jo b ’s pressure.
R esearch study
T hirty-three practicing C anadian dentists took part in a study designed to examine job stress and other issues related to their careers in den tistry. T he twofold objective of the study was to trace the sources and patterns of stress in the job and to determ ine w hether personal factors such as o n e’s physical condition affect the dentist's ability to cope with the tensions of his career. T he participants w ere attending a voluntary dental fitness clinic at the time of the study. D ata were collected concerning the individual’s job, career, and physical condition. Each participant was interview ed and, in addition, com pleted a questionnaire designed from a previous pilot study, to solicit inform ation about his practice, his career, and his feelings about the job. C er tain physiologic variables that are known to be indicative o f an individual’s health also were m easured. T he analysis sought to determ ine trends, patterns, and relationships, with the in tent of isolating the im portant connections be tw een work, stress, and health. The character
Table 1 ■ S c h e d u le b e h av io r and w o rk patterns. Averages In dealing with my dayto-day business I am always ahead I can usually keep ahead of my patients I occasionally fall behind I am continually unable to keep ahead of the clock No answer
N 1
%
Yr in A ge (yr) practice
0.03
29
5
Hr/day
Evenings/month
8.0
0
Lunch time (min) 60
Income ($) 25,000
11
0.33
39
14
8.9
0.73
63
30,600
1 0
0.30
34
8
8.9
1.3
58
29,400
10
0.30 0.03
40
14
9.1
1.9
43
36,200
1
istics of age and the w ork experience of the group w ere as follows: m edian age was 35 years; minimum, 29 years, m axim um , 54 years; median w ork experience was 10 years; minimum, 1 year; maxim um, 28 years.
Work patterns and career history A s part o f the study, the dentists provided infor m ation about the establishm ent of their prac tices, their subsequent mobility, their patients, and their working habits. W hen they started their careers, 46% of the dentists had chosen their location on the basis o f a desire to live in a particular com m unity rath e r than on the advice o f an outside party. Sixty percent had started in private practice rather than in association with other new or established den tists or in clinics. H elp in starting their practice had been derived in m ost instances from other dentists; 60% of the participating dentists indi cated th at they had received the m ost help from this source rath er than from other graduates or the dental school. Finances needed to start the practice had generally not been a problem: 12% found financing extrem ely easy, 42% found it relatively easy, 27% had some difficulty, and only 12% had considerable difficulty. Once the dentists had started in practice their rate o f mobility had been low, with 70% o f the dentists having w orked in only one com munity since graduation from dental school, and 85% in either one or tw o com m unities. Seventy-five percent o f the group had worked in only one or two offices since graduation and 90% in either one, tw o, or three offices. Expected future mobility was similarly low. Only 3% said th at they would be happy to m ove, com pared with 39% who would not mind moving and 58% who indicated an unwillingness to move. T h e difficulty in establishing a clientele in a new location could easily account for this atti tude. Regarding the organization o f their practice, 51% of the group em ployed only one assistant of
any kind and 78% em ployed one or tw o assis tants. T he average working day was 8.9 hours, with a range from 6.3 to 10.7 hours. T he average am ount of time taken for lunch was 55 minutes and ranged from 0 to 90 m inutes. T he num ber of evenings p er m onth that the participants worked ranged from zero to eight, with an average of ap proxim ately one. Forty-five percent o f the d en tists’ patients w ere adults, 25% w ere teenagers, and 24% were children. A pattern em erges, therefore, of the typical m em ber of the sam ple group. H e is m ale, in his mid-30s. H e chose his location on the basis of his desire to live in a particular com m unity and is reluctant to relocate once established. H e had little financial difficulty in getting established, and now works about a nine-hour day. It is also known that the m ajority of the participants were in a general rather than a specialized practice. T he selection of the sam ple was not controlled since it was made up of those dentists attending a voluntary clinic. T here is no evidence, how ever, to suggest that the sam ple would not be representative of C anadian dentists. In an un published work by C unningham , the dentists studied w ere com pared with a general popula tion of working men and no significant differ ences in physical fitness w ere found.
Work, health, and physical condition It has already been noted that the tim e-pressure problem is a fundam ental source o f stress in the dentist’s job. It is not surprising, therefore, to find that m any o f the dentists reported patient scheduling as a m ajor source o f tension and irri tation. Participants w ere asked to state w hether they tend to be ahead of or behind schedule, and the responses to this question w ere cross-referenced against the average values of age, exper ience, the num ber o f hours w orked p er day, the num ber of evenings w orked p er m onth, the am ount o f tim e taken fo r lunch, and income. Several inferences can be draw n from Table 1. Howard—others: STRESS IN JOB AND CAREER ■ 631
Table 2 ■ Schedule behavior, physical work capacity, and stress symptoms. Averages In dealing with my day-to-day business am alw ays ahead of sch edule 1 can usually keep ahead of my patients 1 occasion ally fall behind sch edu le 1 am continually unable to keep ahead of the clock No answer
N
Physical work capacity
S tress sym ptoms
1
1,240
7.0
11
1,134
1.9
10
983
3.8
927
4.3
1
9 2
Table 3 ■ Exercise behavior as re vealed in answers to the question, “ Do you make a specific attempt to get a minimum amount of exercise?” and physical work capacity (PWC). Answer
N
Av PWC
Yes No
18
1,161 846
12
O f the dentists, 60% are occasionally or contin ually behind schedule com pared with only 36% who are usually or always ahead of schedule. Indeed, only one individual reported being al w ays ahead o f schedule. N o t surprisingly, those dentists who tend to be behind schedule work longer hours, w ork m ore evenings, and take less tim e for lunch. A s a consequence, they also have higher incom es. T here is no consistent relation ship betw een age or experience and the ability to rem ain on schedule. T able 2 gives the relationship betw een the abil ity to keep on schedule and m easures of physical condition and o f stress sym ptom s. Physical work capacity was determ ined in this study by having the dentist ride a bicycle ergom eter. T he figures quoted are m easurem ents of the rate of work produced at a constant heart rate o f 170 beats p er m inute (physical w ork capacity 170) and are a good m easure o f the individual’s physical con dition o r cardiovascular fitness. T he stress indi cato r is a simple total of the stress sym ptom s re ported from a checklist of 40 such sym ptom s given in the questionnaire. This sym ptom check list is a com posite list constructed with reference to our previous research on stress sym ptom s. In previous work by us, the list had been used as an effective indicator of stress by both the simple addition of th e num ber of stress sym ptom s re ported and by the identification o f five health factors, using factor-analytic techniques. In this research , a simple addition of the num ber of stress sym ptom s reported was used as an indi cato r o f stress levels. Both indicators—physical w ork capacity and 632 ■ JADA, Vol. 93, September 1976
stress sym ptom s— show a consistent trend with the problem s of patient scheduling. T hose par ticipants w ho are always or usually ahead of schedule have a higher physical work capacity than those who tend to be behind schedule. In addition, increasing stress sym ptoms are asso ciated with the increasing tendency to fall behind schedule. N o t m uch significance, of course, can be attached to the high stress sym ptom s report ed by the single individual who was always ahead of schedule. Along with the findings given in Table 1 (that falling behind schedule leads to longer working hours, shorter lunches, and working m ore even ings), a fuller picture begins to emerge though it is not yet possible to speculate on which are the causes and which the effects. A m ultiple regression analysis was run on the results to determ ine the variables that are m ost strongly correlated with being ahead o f or be hind schedule. Age and experience w ere found to be rela tively poor predictors o f a dentist’s schedule be havior though the trends w ere, as would be ex pected, that younger dentists tend to be ahead of schedule and that experienced dentists also tend to be ahead o f schedule. T he implied contradic tion here probably explains the low correlation. B etter predictors w ere the am ount of tim e taken for lunch and the num ber of assistants em ployed. T he strongest correlation with being ahead of schedule was with physical w ork capacity. Though regression analysis does not establish a causal relationship, it is reasonable to suggest that the individual’s physical condition is at least partially responsible for schedule problem s. This is a highly significant finding and suggests that the best predictor of a dentist’s productivity may be his physical fitness.
Physical work capacity and exercise Since the dentist’s jo b is relatively active, we m ust be cautious o f using the generalization of the relationship betw een one’s physical condi tion and work perform ance with regard to other occupations. It is widely know n, how ever, that exercise is an effective m eans of reducing ten sions and irritation, and in addition, Table 3 shows that there is a significant relationship be tw een exercise and physical work capacity. Thus, for dentists, exercise not only helps w ork off the tensions o f the job but gives a secon-
Table 4 ■ Exercise behavior as revealed in answers to the ques tion, "Do you m a k e a specific attempt to get a minimum amount of exercise?” and stress symptoms. Answer
N
Yes No
18
Av. no. stress symptoms 2.25 4.90
12
Table 5 ■ Age and physical work capacity (PWC). Age (yr)
N
Av PWC
20-30 31-34 35-42 >42
7
1,044 906 994 1,163
8
9 8
dary payoff by im proving o n e’s physical condi tion and thereby his ability to cope with jo b pres sures as they occur. This relationship is con firm ed by relating stress sym ptom s to exercise (Table 4). T hose participants who attem pt to ex ercise suffer few er than half the stress sym ptoms reported by th e nonexercisers. T able 5 shows how the dentists’ physical con dition varies with age. It is interesting to note a decline in the average physical w ork capacity of the participants who are in the m iddle age range from 31 to 42 years followed by a rise after age 42. Table 6 gives som e illumination of this obser vation by including the effect o f exercise. In each age bracket, those who m ade an at tem pt to get at least a minimum am ount of exer cise showed a significantly higher physical work capacity. Only the 35- to 42-year-old age bracket contained few er nonexercisers than exercisers. O f those in the 31- to 42-year-old age bracket, 52% w ere exercisers com pared with an overall average o f 60%. T here is no ready explanation for the high w ork capacity of the older partici pants, though sampling bias might be expected since the group was participating in a program in which physical exercise was to be em phasized. It is possible that the older participants in the program w ould have had a particular interest in their physical condition before choosing to at tend the clinic. The age-related changes in exercise habits also could conceivably be associated with stag es in the participant’s career and in the devel opm ent of his practice. In the early stages, the dentist tends to retain both the fitness and the exercise habits established during his college career. With time, the growth of his practice, perhaps o f his family and his role in the commun-
Table 6 ■ Age, exercise, and physical work capacity (PWC). Exercise in PWC Age group (yr)
Y es (N)
No (N)
20-30 31-34
1,299 (4) 1,026 (6 )
692 (2) 545 (2)
35-42 >42
995 (3) 1,264 (6 )
993 (6 ) 860 (2 )
% exercisers 66 7 5
33 75
\ z
52
ity all im pose conflicting tim e dem ands th at pro gressively break down exercise habits and im pair o n e’s physical condition. W hen in his 40s, with an established practice and a growing fam ily, the tim e-pressure problem becom es less sev ere for the dentist. T he reaw akened interest in exercise and physical condition also may be as sociated with the general psychological phenom enon known as the “ male m enopause” or mid life crises.
Work and stress T h e foregoing relationships can be integrated into a chain of events as speculated in F igure 1. Beginning at the left o f the diagram, we see the dentist overloaded with patients. This assertion is derived from the high correlation betw een in com e and the tendency to fall behind schedule which, given the relatively uniform fee scales, implies that m ore patients are being scheduled per day or that few er assistants are being em ployed or both. T he consequent tim e-pressure problem leads to shorter lunches, m ore evening w ork, and longer working days. This self-inflicted pressure is likely to be prom pted by the dem ands o f a growing practice, which are dependent on the stage of the dentist’s career, and by certain qualities of personality or character. T he participants in this study w ere classified by the Friedm an and R osenm an1 clas sification as to w hether they w ere type A or B persons. T hese authors describe the behavior pattern for type A persons as: An overt behaviour syndrome or style o f living char acterized by excesses of com petitiveness, striving for achievement, aggressiveness (sometimes strin gently repressed), time urgency, acceleration o f com mon activities, restlessness, hostility, hyper alertness, explosiveness of speech amplitude, tenseness o f facial musculature and feelings o f struggle against the lim itations o f time and the insensitivity o f the environ ment. This torrent of life is usually, but not always, channeled into a vocation or profession with such dedication that Type A persons often neglect other aspects of their life, such as family and recreation. Howard—others: STRESS IN JOB AND CAREER ■ 633
Table 7 ■ Satisfaction as revealed in answers to the question, “How strongly do you feel it would benefit you to change jobs or type of work activity?” and physical work capacity (PWC) and stress symptoms. Av PW C
Av stress sy m p to m s
6 6
1,211 1,029
5.0 2.2
18
991
3.3
N S tro n g ly (u s u a lly d is s a tis fie d d en tist) M o d e ra te ly N o t at all (u s u a lly sa tis fie d d e n tist)
T y p e B people, in contrast, are m ore relaxed, m ore easy going. They are seldom im patient and take m ore tim e to enjoy avocational pursuits. T hey w ork steadily, seldom lack tim e, and are not easily irritated. T h ere w ere ten type A and 22 type B persons in th e study. O f the type A persons, 80% indi cated they w ere occasionally or continuously be hind schedule. O f the type B persons, only 50% reported being occasionally or continously be hind schedule. Adding in the effects of exercise and physical condition to self-inflicted pressure, the diagram takes on a disturbing circularity. F irst, the pres sures of the work situation leave little tim e o r en ergy for recreational exercise. This has a prim ary effect on stress sym ptom s, which are not now w orked off, and a secondary effect on physical work capacity that steadily declines and leads to still p o o rer ability to keep to schedule. T h e behavior seen in Figure 1 of the dentist striving to build his practice at the expense of personal physical condition and exercise can probably be seen in other occupations. This would be particularly true o f professions and o ther careers in which the individual has exten sive control over his personal work load. F igure 1 shows the role of individual charac teristics and environm ent and traces the effects through the stress experienced. B ehavior result ing in stress also may be related to w ork and car eer satisfaction.
W o rk and c aree r satisfactio n
Job satisfaction was estim ated by the partici p a n t’s response to the question: H ow strongly do you feel it would benefit you to change jobs or your type of work activity? Table 7 gives the average physical work capacity and total stress sym ptom s for each level of satisfaction. Som ew hat unexpectedly, high physical w ork capacity is found to be associated with a high level o f dissatisfaction, and the trend o f stress 634 ■ JADA, Vol. 93, September 1976
sym ptom s with satisfaction is not consistent. It is possible that stress sym ptom s may be related m ore to jo b dissatisfaction than to exercise. A recent 15-year longitudinal study showed that jo b and career satisfaction are highly related to health and are the best predictors o f longevity.2 It was thought that satisfaction may be related to the num ber of years in practice, o n e’s physi cal condition, the feeling o f patient appreciation of o n e’s w ork, the length o f time spent in o n e’s present location, one’s perception of his work load, o n e’s feelings that the job interferes with his personal life, and the incidence o f stress sym ptoms. T he relative effects o f these factors w ere m ea sured by regression analysis. This show ed the best predictors of jo b satisfaction to be the jo b ’s interference with one’s personal life, the length of tim e in one’s present location, and the num ber of years o f experience o f the dentist. T h at is, a lack of satisfaction in one’s job results from the feeling that the jo b interferes with one’s person al life, that one has spent too long a time in the sam e location, and from a limited work exper ience. T he less highly correlated but also signifi cant factors of feelings of a lack of patient appre ciation, a w ork load that is not perceived as heavy, and high stress sym ptom s are associated with a low level in jo b satisfaction. By combining these factors, we w ere able to build a com posite picture o f the dissatisfied den tist. L ack of w ork experience implies th at a young dentist is m ore likely to be dissatisfied. This is consistent both with a high level of physical w ork capacity and with feelings of a lack o f patient ap preciation. T he absence of patient appreciation probably affects dentists o f all ages, but the dis crepancy betw een perceived appreciation and expectations o f appreciation is likely to be great er for the younger man. Since a dentist spends a relatively long period o f time in one location, it is likely that the dissatisfied dentist m oved to his present location after graduation and stayed there. A feeling that o ne’s work load is low seems to conflict with the feelings that one’s w ork load is a great interference with one’s personal life. G iven the inexperience of the dissatisfied den tist, it is probable that his com plaint of a low w ork load is really an expression of dissatisfaction with the size o f his developing practice. Job satisfaction provides a further elem ent that can be added to the m echanism outlined in Figure 1. T he im pact of job satisfaction is direct ly related to the stress created by the tim e-pres sure problem and the low exercise cycle. W e hy-
FATIGUES
MORE
EASILY
'Type A' C h a r a c t e r
Non-Exerciser More
Overloads Self Wit h P a t i e n t s
Evenings/Month T e n d s To Be ►Behind Schedili e
T a k e s Less ► T i m e For — L un ch
T i me
I
No T i m e Fo r Exercise
Pressure To o T i r e d to Be I n t e r e s t e d i
More Hours/Day
Reduced Ph ys ical *Work C a p a c i ty
More Patients/Day C a reer Phase (Building Practice)
1
High Salary
■ . Uses Fewer As si st ant s
Higher S t re ss Symptoms
Not W o r k i n g ’Of f T e n s i o n Reduced Capacity To« C o p e Wi t h S t r e s s
Fig 1 • In te rp re ta tio n o f re la tio n s h ip s b e tw e e n w o rk p a tte rn s , tim e -p re s s u re p ro b le m s , e x e rc is e b e h a v io r, a nd s tre s s sym p to m s .
Fig 2 ■ In te rp re ta tio n o f a d d itio n a l in flu e n c e o f w o rk s a tis fa c tio n .
p othesize that the stress produced by the den tist’s jo b can be attenuated if the dentist derives a high level of satisfaction from his work. This is shown in Figure 2. Except that both a low level of satisfaction and work overload are associated with the early, building phase of his career, the determ inants of job satisfaction are o th er than the tim e-pressurestress cycle. Job satisfaction, therefore, may or may not be experienced in com bination with the self-inflicted overload behavior.
C o nclusions In recent years, concern about stress has become an alm ost universal topic. Its detrim ental effects on health and longevity are recognized by people associated with the medical and scientific pro fessions as well as by those who are not. P artic
ularly for men, the principal sources of stress are to be found in the area of jo b and career. This is so since it is through his work that the individual establishes and m aintains his identity and selfimage. D ifferent occupations obviously have differ ent potentials for inducing stress. Studies have show n that even specialization within an occu pation can be o f considerable consequence in term s o f m orbidity and mortality. A study by R us sell3 showed that in each of three different pro fessions— m edicine, dentistry, and law—general ists as opposed to specialists had a higher inci dence o f coronary heart disease. Am ong these professions, there is strong evidence that den tists are especially prone to the effects of high stress. C anadian statistics show that the longev ity of dentists is low er than that for the average white, m ale, working population. A fuller under standing of the m echanism of stress production H ow ard— others: STRESS IN JOB AND CAREER ■ 635
can only com e through an integration of the na ture o f the occupation with the character and be havior o f the individual. This is particularly true in occupations such as dentistry w here there is considerable range in which the individual can control the volum e and organization of his own work. In such a jo b , it seems that stress is often large ly self-inflicted; it is the result of acting out, in the jo b and career, th e psychological forces of long ing and striving. Stress is one of the risks o f great am bition. This investigation tends to confirm all of these assum ptions. In addition, though, it has provid ed encouraging evidence that the effects o f stress can be m itigated. Specifically, it has shown the beneficial effect o f tw o factors. F irst, physical exercise has been found to be an effective m eans o f reducing tension and improving the capacity to cope with the dem ands o f the job. Second, notw ithstanding the dem anding nature of his
636 ■ JADA, Vol. 93, Septem ber 1976
w ork, it is possible for a dentist to experience a high degree o f jo b satisfaction. This satisfaction can be an im portant contributory factor to good health.
T h e a u th o rs th a n k J. D an ie ls, W. J. D u n n , D. E v e ritt, M. H agerm an, D. N ic h o ls o n , T. P a la n d i, M. T h o m a s , a n d L. V la c h fo r th e ir a s s is ta n c e in th e c o lle c tio n o f d a ta and fo r p ro v id in g co m m e n ts a n d su g g e s tio n s . Drs. H o w a rd , C u n n in g h a m , and R e c h n itz e r a re fro m th e U n i v e rs ity o f W estern O n ta rio , L o n d o n , O n ta rio , C anada. Dr. G o o d e is fro m th e U n iv e rs ity o f T o ro n to . A d d re s s re q u e s ts Tor re p rin ts to Dr. H o w a rd , S c h o o l o f B u s in e s s A d m in is tra tio n , th e U n iv e rs ity o f W e ste rn O n ta rio , L o n d o n , O n ta rio , C anada.
1. F rie d m a n , M., and R ose n m a n, R.H. T y p e A b e h a v io r and y o u r hea rt. N ew Y o rk , A lfre d A. K n o p f, 1974, p 67. 2. P a lm o re , E.B. P h y s ic a l, m e n ta l, and s o c ia l fa c to rs in p re d ic t in g lo n g e v ity . G e ro n to lo g is t 9:103 S u m m e r 1969. 3. R ussek, H.l. E m o tio n a l s tre s s and c o ro n a ry h e a rt disease in A m e ric a n p h y s ic ia n s , d e n tis ts and law ye rs. A m J M ed Sei 243: 716 J u n e 1962.