The Narcissistic Dentist and the Erosion of the Soul – Bill C.

I encourage you, the music's nice, but the words are extremely powerful. So I just encourage you to listen to this before we get started. Is it okay? This is about learning how to live my life without my best friend, Vodka. Who I said goodbye to 18 years ago. Well, you know I was always the first To arrive at the party Oh And the loss to leave the scene of the crime Well, it started with a couple of beers And it went I don't know how many years Like a runaway train Handed for the end of the line Well, I finally got around to admit That I might have a problem But I thought it was just too damn big of a mountain to climb Well, I got down on my knees and said Hey, I just can't go on living this way Guess I have to learn to live my life one day at a time Oh yeah One thing at a time Oh yeah One thing at a time Oh, yeah One day at a time Oh, yeah One day at a time Well, I finally got around to admit That I was the problem When I used to put the blame on Everybody's shoulders with mine All the friends I used To run with are gone Lord, I hadn't planned on living this long But I finally learned to live my life one day at a time It was something I was too blind to see I got help from something greater than me And today I learned to lead my life One day at the time Yeah, God help from someone greater than me. Wasn't that powerful, the words? I mean, it's just amazing. Well, you know, the two greatest needs of a human being, as we know, are acceptance and recognition. And when we don't have those, our lives tend to be out of kilter. I know that, you Know, we all want to be accepted by our patients. We all want To be accepted and liked by everyone. We want to please everyone, and we want to be recognized by what we do. And interestingly, dentistry attracts a lot of those personalities, compulsive personalities, perfectionism. We have unrealistic expectations a lot OF times about who we are and what we can do, what we're supposed to do. And we do work in a profession where we have limited self-observation. We don't have people that look over our shoulders. We're doing our own thing. Sometimes we have unnecessarily high standards of performance, and we do have isolation-driven traits. And I've already mentioned about the social approval, the codependency that we've talked so much here at this meeting. So if anybody's feeling isolated, let me know. Personality traits of dentists, we are dependent and controlling. We have a sense of entitlement. I've done this. I deserve that. A lot of us handle situations passive-aggressively. Some of us use avoidant personalities. Narcissism, one of my favorite things to do when we go into a treatment center is talk to the staff there. I'll say, you don't have any narcissistic dentists here, do you? They all laugh because we're all narcissistic to a point. Fear, anxiety, and then we have the overachievers, the OCD. And we know we can just read those and identify with probably most of them. I mean, we're cookbook a lot of times in what we do. If somebody's not telling us where to go, what to do, it's got to be perfect the first time. We're unable to delegate. We're rigid, stubborn. You know, Carolina's the only way. You know that kind of stuff. Challenges in practice. Lord, when I made this list up, I was ready to quit dentistry. It just overwhelmed me, all this stuff. I mean you've got, you know, all This Stuff here. I'm not going to read it all to you. But over here for the young dentists in the room, dental school debt, loan repayments. I sit on a committee in North Carolina, and we talk about student loans and debt and what the young dentist is doing when they're coming out of school. And every year it's tabled to the next year because no one has a solution. They have nowhere to go with it. The AGD gets involved, and nothing ever happens. I mean, it's a huge problem right now. We're going to address that later on. Of course, the impact of corporate dentistry and private practice and group practice. If you think about it, these are the roles we play every day. Obviously, I'm not going to sit here and read this, but we do have to make decisions in care and burdens. We have to be the answer people a lot of times for patients. And, I mean, just I challenge you, and when you go back to work on Monday, in five minutes at the beginning of the day, listen to how many times you're asked a question. I mean doctor, we need to do this. So-and-so called. You're making decisions just right and left. We're like a floor manager for a TV show, and your computers go down we have to be an IT expert a salesperson, a conversationalist we have tremendous stamina to do what we do compassion of a priest I learned something early in practice don't ever ask a patient how they're doing ask them how their mouth is doing because they'll tell you about their sciatica and everything else it may be a while but we have made a tremendous commitment to our profession educationally, professionally and financially The physical demands, I remember when I was 22 years old getting ready to go into dental school, I talked to this guy who was in his 60s and I said, what's the hardest thing in dentistry? Is it microbiology or organic chemistry? And he goes, back pain. I thought, this guy, you know. The stress we deal with. We do live a lot in an isolation world, cottage industry. and so from these pressures and these stresses that we have we're more susceptible to burnout and depression and some of us who got into drugs we got that coveted DEA license and we became pharmacists and physicians and everything else and we do work long hours the dental office I don't think there's a person in this room would say that the dental offices is not an emotionally charged area There's a lot of emotions and energy going in there, positive and negative. A lot of times we have unrealistic goals. The patients have unrealistic goes for perfectionism. Physical requirements we talked about. Difficult patients that we work on. We'll talk about that a little bit later about how to deal with those. We do absorb patients' anxieties. You know, the tooth broke. What did I do wrong? What was wrong with my prep? This person's still bleeding. Maybe I didn't. We tend to do that, and I don't think that's just an addict behavior. I think that'S in dentists in general. I think all of us do. Sometimes our jobs do become repetitious and boring, and then dealing with staff and insurance companies and attorneys can get burdensome. This was a study that came out of the Canadian Dental Association years ago. So basically about 88% of the dentists, and I guess that was an overall survey, were in pretty good health in general. But of that 12%, some had problems with that. The most common problem in dentists obviously was the low back pain that we all have either experienced or will experience. Shoulder wrist pain, allergic contact dermatitis, respiratory problems. I was supposed to say respiratory, not respiratory dermatitis. I've never heard of that. See, I'm sort of proofreading it as I do it. Eye injuries, auditory damage, and, of course, nitrous oxide. I want to talk a little bit about this slide. When I went into practice in 1980, and I wantto tell you when I'm talking here, this is my story. This is mystory, so I'm not telling you this is what you need to do or that you're wrong if you're not doing this. This is what happened to me in my recovery. In 1980, when I went in to practice, I just showed up, patients were on the book it was filled I worked and that was it now the schedule can be like an EKG it can be busy, slow, busy just like all over the place which brings on a new stress issue dental practices were more growth oriented when I was in the 1980s, today we're more maintenance some of that may have to do with my age I'm 61 so I'm sort of on the latter years of my dental practice but we're still doing okay but it's not as growing like we did in the in the early 80s uh dental patients today are in the 80s were in my opinion pretty respectful you know they they they listen to what you said and they you know if they had insurance eight out of ten would do what you say now it's about two out of 10 and a lot of factors play into that anywhere from financial to what i call hyper individualism which means that the patient has ultimate control and it's all about them, self-centeredness, entitlement type of attitude. Families in the 80s we had more core based families and now we have many diverse kinds of families so you never know who you're talking to when you have patients coming in. You got a young kid in an office and you go out and you may be talking to the ex-wife's boyfriend and you're like wait a minute we can't do anything until we talk and so you're hunting people down to talk to. Attitudes of dentists. When I came along, everyone I knew was very confident. Some were overconfident. And then today, I think it's a fear base. I talk to young dentists all the time and they're going like, I got this huge debt. I'm very afraid that I'm not going to be able to ever pay that back. And we'll talk about that and also other issues. The economy in the 80s, it was growing it was this was right after carter uh got out of office and reagan came in as tax cuts and we saw growth in america and then it's and i know cycles of the economy go up and down but we're sort of like in a recession kind of a dead zone right now uh dental treatment i did a whole lot more comprehensive patient driven uh co-diagnosing with a patient today it's more emergency driven and insurance driven and dental insurance as we probably know for those who've been in practice for a while, I could tell you to the penny what the insurance was going to pay, co-pay and everything. Now it's a guessing game. It's more complex. You've got all these one year waiting periods and 30 day this and 60 day that. And then we're in a society where the digital technology has taken over and that's sort of what I'm talking about today but there's a term, I don't know if you've heard of it, digital amnesia. And digital ammesia is a new term. It's in medicine right now. It' s huge and they're talking about it with cell bow which is cell phone elbow they're getting like lateral epicondylitis and having to have surgeries some of the nba players are having tohave surgery on the elbows just from talking on the cell phone it's a huge problem but digital amnesia is if i say what's your son's phone number and you go i don't know i hit the button in it we we don't store that any information anymore we store numbers and not phone numbers but you know uh call forwarding or some number we hit so we can't remember things anymore so with that this condition i would like to suggest in my life has caused a lot of stress and fear um i know we all know the definition of stress but i'll just point out that when a human being fails to respond appropriately to emotional physical or chemical threats whether they're actually actual or imagined is when we uh experience stress and Interestingly enough, everyone deals with the stress in different ways. Some people can disseminate the pressures. Others take alcohol and drugs like myself, and others deal with it in their own way. So it's all sort of handled differently by different people. So this is a little three-minute video I'm going to show you, and probably you can leave after this because you'll get all the answers. But let's see if I can play this here. This talks about stress. In a busy world with unending work and responsibilities piling up, stress can get to the best of us. But how bad is it for you, really? Can stress actually kill you? From a biological perspective, stress makes perfect sense. If you're about to get chomped on by a bear, your stress hormones better kick your butt into gear. But it turns out that your mortgage, unemployment, and looming exam all trigger the same stress response in your body. And unlike most animals, which eventually experience a major decrease in these hormones, humans can't seem to find the off switch. Even though it's not life and death, our psychological woes consistently bathe our bodies in these hormones, making our heart pound, muscles tense, and stomach turn. In Japan, they have the term koroshi, which literally translates to death from overwork. In what is now deemed an overworking epidemic, these individuals who are seemingly healthy and in their prime suddenly die. After being officially recognized and documented in Japan, these sudden heart attacks and strokes were quickly linked to stress. But how does stress cause this? Cortisol is one of the main stress hormones which helps divert energy to where you need it and away from non-essential functions of the body. But with chronic stress exposure, problems arise. The immune system shuts down, inflammation is inhibited, white blood cells are reduced, and susceptibility to disease increases. Some evidence also suggests that prolonged stress may be involved in the development of cancer. When looking at the arteries of macaque monkeys, those under significant stress have more clogged arteries. This prevents blood from getting to the heart quickly during stress and can ultimately lead to heart attacks. The brain also takes a toll. When looking up mice exposed to stress, we see dramatically smaller brain cells with fewer branch extensions than normal mice. This is particularly prevalent in the areas associated with memory and learning, which may stir up some memories for you of those wonderful all-night study sessions. The acute stress and sleep deprivation can make it increasingly difficult to remember the things we want to. Perhaps the most telling story is in our DNA. We contain something called telomeres at the end of our chromosomes, which decrease in size with our age. Our video on aging here explains this process. Eventually, the telomere is run out, at which point the cell stops duplicating and dies. So, telomeres are directly related to aging and length of life. And it turns out, stress may actually accelerate the shortening of these telomères. But not all hope is lost for the perpetually stressed. Another hormone, oxytocin, has been shown to reduce this stress response. It helps your blood vessels relax and even regenerates the heart from stress-related damage. So, how do we get more oxytacin? It's sometimes dubbed the cuddle hormone because it's released during positive social interactions and while caring for others. People who spend more time with others create a buffer or resilience to stress So when life gets the best of you, just remember You don't have to go it alone Spend some time with those you love It may just save your life So now you know why we hug at AA, right? Just a little bit on stress right here Don't try to read all this But the general take home here is that When we have moderate strength of stressors you tend to do pretty well, even if it's short-term or long-term. When we have high long-terms stress demands over long periods of time and high stress demands, it brings in a lot of anxiety, depression, and burnout. And you can kind of see this in the graph. We kind of want to stay in this yellow zone here. And when we get too much stress for too long, too much, it turns into exhaustion, and then we have a burnout. We're going to talk about burnout. Some of you guys know Jerry Groper. He's been around for a long time, but I love this. In an article he wrote, he says, Stressors in dentistry, we have the eye of an artist, sculptor, hands of a surgeon, the insight of a therapist, the tact of a diplomat, reasoning of a science, and skills of a business person. There was a study recently done with 3,500 dentists, and the first three lines there basically show that we think our profession is very stressful. We're frequently worried, anxious, exhausted physically, emotionally, headaches, backaches. About a third of us think that. Like we've already talked about, mostly report lower back pain, other headaches, intestinal problems, anxiety and depression. And then the lack of training and skills to manage office staff and your office effectively and consistently. It's a huge stressor. good stress causes feelings of low self-esteem i mean excuse me stress not good stress or eustress causes feeling of low selfishness depression anxiety and hopelessness and it's interesting that this was a study done by the ada that only 40 percent of us actually seek help that are oppressed and younger dentists are actually more prone to stress than some of the older dentists. The two biggest causes of stress in the dental office, and I think we can all relate to that, running behind schedule and coping with difficult or uncooperative patients. And this research showed that actually running behind is more stressful than dealing with a difficult patient. So I've had that experience this past week. The perceived stress scale, PSS, that they did on dentistry shows the intense stressors in dentistry We mentioned that right there, so you can kind of see what we deal with on a daily basis. So altering one's perception of stress and improving one's coping skills will help to reduce stress, and we're going to talk about that. I like this cycle of worry. When we're at work, we're under a lot of pressure. We're thinking about being at home and just relaxing, and so when we get at home, we'RE thinking about beINg at work because we didn't finish something, and it just keeps going, and that's stressful. We can't turn our stress hormone off. Remember that little button he had, the light switch on and off? We can just say, that's it, turn it off. Sometimes we can. Tammy Bell, who's a social worker, actually works in relapse prevention in the Charlotte area, said something that I asked her actually last week or week before last, and she said, yeah, I quoted that, so I'm giving her credit for this. An addict dealing with fear or stress, she says, our thoughts are irrational, our emotions are unmanageable and our actions are self-defeating. Just pick a stressful situation that you've been in in your life and practice I mean I can think of dozens where you know a patient calls and says they're still having problems with something. Well you automatically have gone to a root canal you got to take the tooth out and pay for the implant to replace the tooth and then the emotions are un manageable. You're going like how am I going to deal with this and then all this is self-defeating so i mean it's it's this very stressful um situation anyway anxiety orders i'm not going to spend a whole lot of time on this slide but oh and by the way if anyone wants these slides i'll be glad to send them to your drop box so you're welcome to them or email them they won't email because there's pretty big uh file but i'll being able to send it to you as a drop box link but um we know that 40 million americans over the age of 18 deal with anxiety disorders. The cost is astronomical, and we also will notice that the two most common anxiety disorders are panic attacks and GAD, or generalized anxiety disorders. Interestingly enough, panic attacks are usually treated with either medicines or psychotherapy, and with GAD you usually have to treat that with medication. Women are twice as likely to have PA or GAD than men with panic disorder having the highest comorbidity rate and a lot of times turns into depression. The medications we talked about here, of course I put here benzos, not necessarily for the addict in that situation. There are other ways. Stress relievers, that deal that will help stress to kind of diffuse stress. I'll have a slide later on that I'll talk about physical exercise and working out. It's an amazing conclusion that this study did. But we find that working out, walking, running, jogging cannot be over or cannot be underestimated in relieving stress. Brett, you're a big stress guy, I know, and you love to keep active, and it really helps because it burns excessive adrenaline and increases your overall well-being. Individuals' personalities and temperaments have a huge effect on how we deal with stress. So in other words, when someone tells someone who's always a down-and-out kind of person that's very negative and they say, you just need to have positive thoughts, happy thoughts, and your life will change, that's foreign to them. They don't know what that means. So they have to be trained and taught how to deal with that. So our personalities and our temperaments have a lot to do with how we perceive stress. Obviously counseling and therapy, and we know that AA and NA works and how it works. Interesting, I threw this slide in here, and maybe this is why I do what I do, but it said that studies show that dentists who take on teaching or leadership roles with other professionals in addition to their clinical practices, that it's a stress reliever. I thought, well, okay, so why is that? Well, it lessens our isolation. It increases our self-esteem because we're responding to the attention from dental students or an audience, if you will. You have a sense of autonomy of what you're teaching. And you can read the other ones there. But I think it's interesting, that's just another way to get out of our isolation, to get outside and give back in service work, either talking about our profession or how we dealt with our addiction. So if someone ever asks you to speak in public about your... And actually, Enrico, his group in Greensboro asked me to come and speak. That was a wonderful experience for me, a group of doctors in Greensborough. and I came, and they were physicians, but I talked to them. And dentists, you're a dentist yourself. And we talked about, Enrico's a dentist. You're a dentist? You're not a dentist? I thought you were a dentist." Well, okay, we'll give you an honorary dental degree. But anyway, there were physicians and dentists there. And I had a great time to go and give back, and it gave me a chance to get out of my shell to go in and share. So if you ever get a chance, do it. Depression. I'm going to read this because we're going to take this term, depression, and go to burnout. Depression is an unpleasant mood state characterized by sadness, despair, or discouragement. It may also involve low self-esteem, loss of interest in usual activities, social withdrawal, and somatic symptoms such as eating or sleep disturbances. Depression is more than simply a feeling of down in the dumps for a few days. Symptoms of depression can last at least two weeks. And I know this came from the DSM-IV, but DSM 5, I didn't look that up. But this is the definition. So I heard a counselor one time tell me that someone who's depressed a lot of times is they're flatlined. If you tell them something's great going on, they go, oh, that's great. You tell them some bad's going on and they say, oh that's right. They're emotionally burned out or flatlined Types and prevalence of depression, you can see the things that we see. the most common signs we know that the mean onset is around early 30s and women are twice as likely to be depressed or have depressive disorders than men we sometimes can see different changes in our weight or appetite sleep, hyper sleep, less sleep, fatigue feelings of worthlessness, thoughts of suicide inability to concentrate and the reason I bring this up to you is because as dentists and as in my story i'm so exhausted sometimes i'm thinking what is the exhaustion coming from it's because i'm not getting enough sleep because one of the things you'll you'll find here is that your physical symptoms are major indicator of what's going on with burnout and that's what we're sort of talking about here uh i do want to talk just a minute about depression and forgiveness there's a tremendous correlation between the two um 90 of all depression has some something to do with unresolved anger uh holding on to justified and unjustified resentments and fear uh two sayings that i i found that i really like forgiveness is the best gift you will ever give but also the best guilt you'll ever receive and one day i was in a one of the um i was doing a urine sample um and i was waiting there was a sign on this lady's door and it said forgive others not because they deserve forgiveness but because you deserve peace. You think about that. You deserve peace, forgiveness is for you. And let me tell you what forgiveness is not because there seems to be at least some confusion as to what forgiveness and what it's not. It's not approving. When you forgive someone, that doesn't mean you approve of their action or you're belittling what they did. You're not enabling sin or wrongdoing when you forgive somebody. Sometimes you forgive, I mean, obviously the people down in Charleston who had that terrible catastrophe that happened with the nine people killed, those family members were forgiving this young man not because they were trying to say, well, go out and kill again or it's not a big deal. They were just doing it for themselves to be released from that bondage. It's not denying a wrongdoing. It's nicht waiting für eine Entschuldigung. And there seems to be this thing about when you forgive somebody, you'll forget it. You'll never remember it again. That's not true. You'll never forget it, but the pain, the sting won't be there as long as you keep forgiving them. And sometimes, just like it says in number seven here, it's not a one-time event. You have to do it over and over. Neglecting justice is not saying, well, you know, you stole this, you murdered this person, whatever. I forgive you. You don't need to serve any jail time. That's Not What It's Saying At All. You still have to let justice play its role. You can still forgive them and still convict them. and trusting. You know, trust is lost quickly but restored slowly when someone that you've trusted and they do something against you you know, trust is loss quickly but they have to sort of like we do in AA have to have a living amends to bring back that trust so when your wives or husbands or significant others whatever you know say well you've only been stopped drinking three you hadn't drank in three weeks and you want me to all of a sudden say everything's fine again? No. It takes time so you do your part Just, you know, do the living amends. And then reconciliation, that's really when the pain of forgiveness starts to subside. In reconciliation, it takes two people. It takes one to repent, it take one to forgive, and two to reconcile. So at that point, hopefully, in a relationship, that reconciliation can occur. Did you have your hand up, Brent? I thought you were doing this, I'm sorry. Okay, good. so anxiety stress depression in dentists we are predisposed i guess to depression um anxiety depressive disorders interestingly enough and i started to do a section on this but i didn't there's no statistical evidence that shows that dentists are more likely to commit suicide i can give you the short version where that got started back in the 60s there were four dentists in the state of Washington who committed suicide and so somebody said I wonder if dentists are higher more likely to commit suicide and then they found out that farmers and people who shear wool off sheep are higher than the dentist. We were up there with the wool shearers and the farmers so I don't know what that's about and then you had airline control people You remember that study. But then in the 70s, at UNC, the dental society or the dental school did a study and found out there's really no correlation between suicide. It's multifactorial. It's not just the profession causes you to commit suicide. There's other things going on. And let's see, what was the other thing I was going to tell you? Oh, there have been some indications that young female dentists have a higher suicide rate and older white male dentists have higher suicide rates than the general population of dentists in, you know, like between 35 and 60. And I don't know if that's the stress of starting a practice and the stressof ending a practice. We feel a little stressed, don't we, trying to end a practice because I'm hopefully going to retire in the next few years. So dentists, interestingly enough, we do enjoy a healthier lifestyle. Usually physically we're more active than a lot of our other health care professionals, but we do suffer more from mental illness, and it's been shown to be poor. And we also are bad about seeking help because of our pride. And I don't want to be sexist here, but I think a lot that's the men. I thinka lot of men will not get help. The women, you'll see a slide on burnout here in a minute that will talk about females. Self-care, I won't go into a lot of this, but we know that there are ways to kind of chip away at depression, obviously counseling, getting help, asking others for help, postponing important decisions until the depression is lifted, just practicing positive thinking I was talking about, and letting others help. So it's a WE program. And also exercise, movies, ball games, religious and social activities. I put this in here because I want to talk about the thing that I probably deal with the most, and you too, is managing difficult patients. These are some suggestions that were made by an article that I read that I thought was very good. It said try to recognize the negative emotions in yourself when dealing with a patient who is angry or upset. So in other words, don't overreact. Let the patient talk. Don't try to talk over them. Identify what is difficult about an interaction with a person. If the patient is just bludgeoned out of control, let them kind of diffuse for a little bit. Clarify and roll expectations between the dentist and the patient. Make sure that you're not taking on more than you're really dealing with here. In other words, if the patient has just lost a child to an accident through a death and you know the patient's depressed and you have the patient on antidepressants and having some issues, don't try to fix it through your words. Just kind of let them vent and kind of Let them explain what's going on. But also the last one down here, maintain your boundary between your patients. You can't be a fix-it-all. Sometimes they just have to yell and scream and do what they have to do. But try to remain calm and repeat that you've heard what they're saying and let's see how we can rectify this. I mean, it's a difficult thing. I don't have the answer. You guys probably have more experience in that than I do. but it's a difficult thing to deal with. There's a technique that's common or has been used before called the BATHE technique, how to reduce stress with dealing with difficult patients. The B is to assess the background, sort of like what we're talking about. A is to try to understand the effect or emotion evoked by the problem. T is focus on actually what's troubling them, and H is note how the patient is handling the problem, And then E is obviously show empathy, but again, it's not that you're going to just cave in and give them what they want necessarily because sometimes that's not the appropriate thing to do. So you can actually go online and read about this technique. Stress in the young dentist, and I know we've got some young dental dentists here this week. Stress starts early. In the U.K., this study was done in the U。K., and I don't really know why it would be that much different than here in the United States, but increased patient loads when they get into practice, financial pressures, expectations from being a new associate, fear of litigation, making mistakes, demanding patience. These are stressors that begin early in life. In the U.K., they show that a lot of the dental students and young students actually drank excessively and experimented with illicit drugs. Now, that's not surprising. I mean, we all know that to be true here in the States. But interestingly enough, in the final year of the dental school in the U.K., 67% of the students had experienced some possible pathological anxiety. And it kind of reminds me, there's a study that was done at University of Texas Health Sciences about six years ago, and they compared dental students with the general psychiatric patient population. The take-home message was that they found out that almost a third of the dental students came away with some. If they were, like, coming out of dental school and they were actually getting a psychiatric evaluation, they would actually be diagnosed with a psychiatric disorder, at least a third. I just wanted to say that there was a dental student who was president of ASDA, the American Student Dental Association, and he committed suicide the year after she finished her ASDA term. And Phil and Curtis and I set up a dental well-being advisory committee for the ADA, and before that happened we were telling them we need to get in the dental school to provide them just information and know that they can get help through the legal committees and stuff like that. It took us a month or two later, and then we ended up passing a resolution Yeah, yeah. And thank you, Brett, for that. ASDA is the American Dental Student Association. COTA is the Council on Dental Accreditation. And those are the people you have to convince to change your curriculum, and it's pretty involved. But we do have a young man, I think he's about 31 years old, that's now an ASDA representative on DWAC from Texas, I believe he is. And he seems very energetic and very enthusiastic about helping. So that's good. Yes? There are some studies to show that. In fact, one of the things that – and some of you have heard me say this already. I apologize if I say it again. But I really think that as a dentist, when we graduate, we sort of – dental school kind of breeds competitors and medical school kindof breeds colleagues. And we're going to talk about that in just a minute. I'm glad you brought that up. I think that might be the next slide actually. Nope, still talking about dental student debt. But it's coming up. This is a study that was done in 2012 and we've seen that the average student debt in dental school has doubled since 2001. Average tuition, this is kind of a hard slide to read, but the average tuition for in-state dental schools is around $39,000. Out-of-state is $53,000, and interestingly, 75% of those will have an overall debt of over $100,000 when they go into private practice. I tried to write it out more this way. In 2013, ADEA, the Education Association, at the graduating class showed an average debt of $284 for private schools and $209 in state schools, and that's the total debt. Historically, we were in situations where solo practitioners were the predominant model. And, I mean, literally back in the 60s, 70s, 80s, and 90s, and even early 2000s, you went to work, you worked, you did the best you could, and you made a living, and there wasn't a problem. And then when the recession hit, that kind of a lot of different things are happening now, as we all know. This fact, to train one physician, it takes one hospital bed. Excuse me, four physicians or medical students, it take one hospital bid. But for each dental student, they need their cubicle and their chair plus their equipment and all their instruments. So it's a very expensive educational system. Another dynamic that's going on that's adding, I think, to the stresses in dentistry. In the last, from 1986 to 2001, we've had seven dental schools to close and we've Had 14 Dental Schools to Open in 1997 to today. And you can see these schools, some of you may be teachers there, I don't know. But we've HAD 14 new ones. And we found out that it's not so much a shortage of dentists as it is a maldistribution dentist. So they're opening up schools in kind of obscure places like Nevada and two dental schools in Utah, and at the time they had no dental schools. Anyway, in April 2012, ADA reported that there's been a 25% increase in the number of large group practice and a 25%, increase in corporate dentistry. So you're seeing kind of a shift going away from the solo practitioner model to more corporate and more group practices. This is kind of conflicting results here. I'm not really sure what to make of this, but I guess one thing you could say that's a low number of respondents, 75 dentists, but they were asked about what the future of dentistry looked like. And interesting, if you do the math, about 66% of us say it's kind of pessimistic or uncertain, and so you've got about 37% that are very optimistic. However, U.S. News & World Report put us at the number one job to go into as the 100 best jobs. And the Bureau of Statistics say that there will be an average growth of 21% between 2010 and 2020. Of course, there's other factors in there. Let me talk about our dental assistants, dental hygienists, front desk. You know, I was surprised how much work there was really out there on that, But the three most common things that come up, they see themselves as their roles are very ambiguous. They feel like they're underused for the skills that they've been trained for, and they have very low self-esteem themselves. So a suggestion that I started doing years ago, and a lot of you, I'm sure, do this yourselves, but observe boundaries with your employees. That's the number one thing. Don't go feeling and hugging and all this stuff. We're professionals. We have to respect our boundaries, and you know that sexual harassment, occupational harassment is a huge thing right now. So that's the number one thing. Don't fraternize with your employees, so to speak. I mean, you can be nice to them, take them out to lunch and stuff, but just keep your boundaries. Two words that I've said since the day I started was thank you, and that goes a long way. When people tell me thank you that goes along way with me. I give things to them at Valentine's, Secretary's Day, Christmas, different things like that. Just little things that keep them interested and engaged. Appreciation cards at Thanksgiving, tell them how thankful I am that I have them as employees. I don't do it every year. I don' t want it to be a routine like they're expecting it, but I do it occasionally. And then staff lunches, I try to do at least four to six a year. That' s just what I do. Now, burnout. here is the definition of burnout because every one of you when I first started this I thought burnout was about stress burnout is the index of dislocation between what people are and what they have to do it represents erosion in value dignity spirit and will and if I can this right here it is an erosion of the human soul it is a malady that spreads gradually and continually over time putting people into a downward spiral for which it's very difficult to recover. And Maslach, I think I'm saying that name right, Dr. MaslACH has done a lot of the major research in this area on burnout. So if you ever want to Google that name, you can read all about burnout. But I'm going to try to give you some of it here. Let me show you a video here. See if you can relate to this. the actual meaning of stress is to quickly prepare your body for action in case of danger but it also arises when we are for example worried during stress the adrenal gland produces three hormones cortisol adrenaline and noradrenaline cortisol causes an increase in blood sugar providing the body with a lot of readily available energy. Adrenaline and noradrenaline enable the body to perform quickly. This is also called the fight-or-flight reaction. Extreme or prolonged stress can cause your body to function beyond what it can voluntarily do. This can lead to various physical symptoms and disorders, or burnout. A burnout may be caused by prolonged exposure to stress at work, such as excessive workload or too little recognition combined with certain personal characteristics, such as perfectionism, excessive conscientiousness, and workaholism. During a burnout, you have no interest in your work. You feel constantly restless and tense, and you often suffer from physical symptoms, concentration problems, and forgetfulness. Other effects may include little time and energy for oneself and your family, increased drug use, high blood pressure, heart attack, stroke. If you have a burnout, it is very important that you see a doctor for help. He can refer you to a psychologist and possibly prescribe medications such as antidepressants or sleeping pills. During therapy, a psychologist examines the factors which have contributed to the emergence of a burnout. You will learn to take better care of yourself and to create more balance between your work and your private life. Furthermore, the aim is to let you get back to work as quickly as possible. And that's basically, she goes on a little bit more, but yeah, we'll keep the sleeping pills off the list there. There are other ways to deal with that. Again, burnout is a gradual erosion of the person highlighted by emotional, mental, and physical exhaustion, depersonalization, derealization dehumanization you're like you're not real sure where you are who you are and what's going on burnout is a process as well as a condition and one of the greatest indicators of burnout is pay attention to your physical health when your physical help is bad you may be experiencing a burnout so the number one sign of burnout is I don't feel good figure out why you don't feel good In a survey the ADA did, they asked, Dennis, have you ever suffered from professional burnout? Of this survey, 81% said yes. And the most interesting thing that I hear, I do a lot of talking for CERAC, the digital imaging people, is we're getting 30-, 31-, 35-year-olds saying, I'm burned out, I have no interest in what I'm doing, I'm just totally physically exhausted. So it's not necessarily age-related. It's not in my age group. It can be any age. And burnout is easier to prevent than treat. That's the number one thing I would remember. Listen to your body. Your body is telling you what's going on. Just to summarize this, it is burnout is interactions with other human beings. It's not doing too much work. Human beings wear other human being out. When we have this patient relationship, It's very draining to have all these demands that we experience from patients. Burnout, what it isn't, it's not necessarily stress. It's not stress. Stress may be associated with burnout. It's saying, you know, I can't concentrate, I had a bad day, it's been a stressful day. It's long-term. I'll show you this slide here just briefly, stress versus burnout, talking about stress. You get overengaged, you get hyper, all this cortisol and epinephrine and all the stuff get to go, adrenaline get going. And then burnout, you sort of get disengaged, don't really care. Emotions are overactive. Emotians are blunted. But anyway, you can go through this whole list. But interestingly, this came out of a survey done of ministers. So it's not just dentists. It's all professions because who works more with people than ministers or rabbis? I mean, you know, they're always constantly working with people. And they're very draining. Psychologists. Have you ever seen a psychologist? Now, there may be some psychologists in the room. But have you ever seeing a psychologist that's like, oh, here I am. They're always like, the ones I know are just always kind of like exhausted. I mean, you know, maybe I shouldn't say that. A lot of study has been done with symptomatic burnout in physicians. Not so much with dentists, but I'm kind of extrapolating some of this stuff. And I know we have some physicians in the ring that may be able to relate to some of this. In the last 20 years, they've shown that physician burnout occurs on an average of one in three medical doctors on any given day, regardless of the specialty, the country they practice in, or the health care system they practice.