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Burnout: The Dental Pain No One Mentions by Stuart Krohn, DDS

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Dentistry is a tough profession. Unlike other professions, we dentists wear most of the hats at work. We're responsible for the financial health of the business and the hiring and firing of staff. We're the main cheerleader responsible for keeping up morale. Some days we're the maintenance expert, taking care of day-to-day repairs. And of course, we're the main source of revenue.

Most other businesses have a staff of people, all of whom are usually responsible for just one of these aspects of the business, and are able to put their entire focus on just that job. We don't have that luxury. In addition, while other businesses will keep generating revenue when the boss isn't present, nothing is produced if we aren't working on patients.

It's a great privilege to restore someone's functionality, confidence and sense of self-worth, but the other side of the coin is that we are the ones responsible for a good outcome on a dynamic system that has opinions, feelings and a point of view. If I work on my car, I can enjoy doing similar things that I do on my patients, but without the car saying it's unhappy with how I treated it, complaining that it waited too long to be seen, talking about whether or not I was gentle enough with it or if the part I replaced was as shiny as it should be.

The grind
As dentists, we are responsible for great aesthetic outcomes, but we also cause pain to accomplish this. More than half the population doesn't see a dentist regularly because of the pain and discomfort they perceive we inflict. How many times have you heard patients say they would rather have a baby or go to the gynecologist or have their mother-in-law visit for a week than go to the dentist? How many times have you heard, "Nothing personal Doc, but I hate being here"?

We have a heavy responsibility for people's welfare. While we don't make daily life-and-death decisions like our emergency-room colleagues, we do treat people every day who are in pain, show up with infections, or are unable to eat or smile, and the onus is on us to resolve these issues.

In my first practice I belonged to three study groups. A common refrain among participants went something like, "I love dentistry, but if I could get out I'd do it tomorrow." I felt the same. After almost 30 years of practice, things had become pretty stale. As a GP, I only referred out ortho work, perio surgery, and implant placement. In addition, I was licensed to do both conscious and general anesthesia, so I did a lot of long, complex restorative cases, and I did enjoy the complexity and challenge of what I was doing. But I found myself becoming more and more bored, resentful and unhappy. I was happy when someone cancelled an appointment, or just didn't show up. I was much happier relaxing, or leaving the office to do something fun. This created an increasingly depressed atmosphere in the office—the staff was unmotivated, and patients pick up on this sort of thing pretty quickly. I'm not sure how we even got patients to come in.

Not only did this create an uncaring atmosphere, but everything else suffered too. We didn't collect fees very well; insurance claims were slow to be sent out; we didn't pursue money that was owed us (either from insurance companies or patients); and the office decor suffered, as did all aspects of the practice. Without an interested, capable leader at the top setting a positive example, the office was slowly wilting. My clinical skills are strong, and this carried me along (even on autopilot, at times), but without a good attitude and interest in my work I was not at my best.

The bind
Early in my career I was at lunch with a local oral surgeon (to whom I referred cases), and he asked how many days I worked. I told him five per week, and he said that was too many. He said dentistry is too hard—physically, emotionally and psychologically—to do it for more than four days a week. He was right. I cut back to four days, and that's how I practiced for the rest of my career. I always thought that three days would be ideal.

Now, I know that there are a lot of really good practitioners out there who are happy in dentistry, enjoy what they are doing and are constantly learning and improving their skills. Many of my colleagues from the study clubs were excellent practitioners with well-run offices who did their best for their patients and were very profitable. Still, many of them expressed the wish to be out of dentistry. The profession just took too much out of them.

After 30 years, I could no longer shrug it all off. I was fried. One of my best friends, a very successful endodontist, sold his practice when he turned 55, citing many of the same reasons I've listed above. He became a stockbroker, and has said many times over the ensuing years that while his current occupation has its own set of anxieties, it paled in comparison to the anxiety he experienced as a dentist.

I decided it was time to quit. It took about a year to find a buyer, and then another six months to work out all the details and close the deal. When we signed the papers I felt this huge sense of relief, and for the first time in a long time, I felt free. I swore I would never practice dentistry again. I let my license lapse, and started to put dentistry behind me.

The find
And now, six years later, I'm back in the game, in a new office, and I couldn't be happier. I can't wait to grow to the point where we are fully booked every day. I'm excited about what the day is going to bring, what procedures I'll be doing, and when the day is over, looking at what I'll be doing the next day and planning how I can do the best job possible for my patients.

I'm amazed at how different I feel in my new practice. I ask myself all the time how this happened.

After selling my practice, the sense of release was tremendous. I had no responsibility for anyone, no daily, monthly, and yearly income goals to meet, no bills to pay or payroll to meet, no liability, patient complaints, and all the million other worries of running a successful practice. I met friends for lunch, pursued hobbies, got my pilot's license (well, almost), traveled and read. I wasn't bored for a minute—at least, not for a very long time. Then I joined the Peace Corps and spent 27 months in Moldova doing health education (no dentistry, as the Peace Corps does not do any direct patient care). Near the close of my service in Eastern Europe I began to wonder what was next.

The rewind
To my complete surprise, I realized I wanted to do dentistry, but in a way that was completely different than before. In order for me to get back into practice, I decided that certain criteria had to be met.
  1. I would limit the number of patients I see. I did not want to bounce from one operatory to another. I decided to give myself and my patients the time, attention and caring that is deserved. My approach is, "What would I do if this were one of my children in the chair?" My mindset is to work carefully and enjoy the procedures I do, pay careful attention to them, and not have to be pressured that there is a waiting room full of patients.

    I hate to admit it, but in my first practice, the factor of how much revenue a procedure would produce was always in the back of my mind when I considered different treatment options. A friend of mine who's an OB/GYN told me he never wanted to know what insurance a patient had, so that what they paid for procedures would not—even subtly—influence his decision-making. I adopted the same system, but I can't honestly say that despite my best efforts to be objective, the income potential for a procedure wasn't unconsciously affecting my tone of voice, or the words I chose to describe one option or another.
  2. I would do only what I enjoy doing. I wanted to learn to place implants and spend my time placing and restoring them. It turned out that I need to do a lot more to survive economically, but that is just fine with me. In fact, I'm enjoying all phases of dentistry. I still don't like doing hygiene and I'm not at the point where I can pay a hygienist, so I'm doing it myself—but not a lot. I also don't do molar RCT, at least not when I have something else I can schedule.
  3. "Giving back" has to be a priority. Two newspaper articles had a great influence on me and my decision to go back into dentistry. One detailed the exorbitant cost of getting hip-replacement surgery here in the United States as compared to other countries: the same procedure using same joint manufacturer, the same care and skill of doctors and hospitals, and same success rate. Find it at: www.nytimes.com/2013/08/04/health/for-medical- tourists-simple-math.html.

    The other article was about happiness. Research has shown that people are happier when they give rather than get, and this begins at a very young age. I have learned from my own life experiences, including my time in the Peace Corps, that for me this is absolutely true. I'm much happier giving to others than gathering more material stuff, most of which I don't want or need.
  4. I'm going to see this through to the end. I'd like to be successful, but in a way, it doesn't matter. It's the grit that counts—getting through each challenge with courage and determination. If I fail, I won't have any regrets.
  5. I would live near the office—I'm done with long commutes. It's a little hard for me to admit that I'm living in my office. It saves me from an additional monthly expense I can't afford right now. To be completely transparent, I'm not poor, but I'm not rich either. I've decided to either make it—or fail—in this new venture, completely on my own merits. I have taken out some loans and put some of my own money into it, but I am going to sink or swim on the strength of my beliefs and ideas alone.
  6. I would practice three days a week. That's what I thought at first, but I was wrong. I'm working a full week, and I'll gladly come in on Saturday to accommodate patients.

    All of this depended on getting my license back. Fortunately I got in just under the wire, literally with only weeks to spare. I had a ton of CE credits to earn and mandatory courses to attend, and so my first few weeks back consisted of traveling all over the country, taking classes.
The mind
So what changed so much that I looked forward to going back to what I had so eagerly left? Attitude. I've learned that we make our own happiness, and attitude is the determining factor—not what happens outside, but what is inside. I had regarded dentistry as a job, a way to make money, and the difficulties of practice were the price to be paid for success.

What I've learned is that it wasn't the work or the patients that were the problem—it was me. Now I've found that going to the office every day to help people lead better, happier lives; challenging myself to be the best I can be, to learn and improve my skills every day; and interacting with staff and patients in a caring atmosphere, is rewarding beyond anything I ever had in my first practice.

One of my first patients in my new practice was a man in his eighties who was missing some of his upper anteriors. He said that when he took pictures with his grandchildren he was never smiling (because of the missing teeth), and he didn't want them to remember him that way. In my first practice I would have heard this story, thought it was nice, and started to add up how much production I would generate from doing a bridge.

Now, I think of what a wonderful service I will be doing for this man and his family. I won't say that making a good income is unimportant to me—it's just not the first and only aspect of what I do.

The kind
Most important of all, I've learned gratitude. When I am grateful for all I have in my life, my day is filled with opportunities to be happy, to share with others, connect with the people who come in for my services, and truly listen to them and what they want.

I was a teenager when The Beatles exploded on the scene. When they sang, "And in the end, the love you take is equal to the love you make," I (along with everyone else) thought that was really profound, but without really knowing what it meant.

It turns out it was absolutely true: The more of yourself you put into the care and well-being of your patients, the more you get out of it, in every way.

I believe that even a young dentist will be more successful, both financially and in personal satisfaction, working on not only his or her clinical and business skills, but attitude skills as well.

I suggest taking the attitude that each and every patient is a gift—one we are responsible for taking care of. A patient is not just an opportunity to fill in the daily production numbers, or a chance to try out the new material or technique we learned, but a person with the same goal in life as ours—to be happy. It is such a privilege to help them meet that goal.

Before I walk into the operatory, whether I'm seeing a new or existing patient, I stop for a few seconds, take a deep breath or two and clear my mind of anything else that is going on in my life.

Then I step into the room, sit down opposite the person in the chair, and am ready to listen to him or her with an open, fresh, attentive mind, giving that person my full attention, seeing not just another patient, but another human being.

This is my purpose. This is my life. It is new and joyful, and every day I am grateful for the path that brought me full-circle—back to the patients I serve, and the profession I have learned to love.



Dr. Stuart Krohn is a general practitioner in Rockville, Maryland. His practice, Rockville Sedation Dentistry +, focuses on implant and restorative dentistry, including the use of small-diameter implants. He can be reached at drskrohn@gmail.com.


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