Introduction

In 1201, an Association of Barbers was established in France.1 This association would eventually split into two categories – surgeons who trained to perform complex surgery and barber-surgeons who performed more routine procedures including shaving, bleeding and tooth extractions. The latter group would continue to evolve and form the dental profession we belong to today. Dentistry began as a cottage industry with many, isolated practices. Even today, 58% of the profession2 remains in solo private practice where the dentist is chief executive officer, chief financial officer, chief operations officer and the frontline staff. However, large group practices are emerging3 and there is a need for dentists to develop strong leadership, negotiation and collaborative skills. Is the dental profession prepared? In this paper the author will argue that many inherent characteristics that contribute to a dentist's success are actually in conflict with good leadership skills. Subsequently, dentists may be unprepared for the future of the profession, which will involve leadership of large, multidisciplinary teams and the 'erosion of solo practices.'3

Opinion

As described earlier, dentists in solo-practice are owner and master of their business and none of their staff would feel the same sense of ownership or authority. Therefore, the dentist has to do very little negotiation to persuade her/his team to achieve her/his goals. However, a good leader must be adept at influencing their teams, partners and stakeholders into supporting their goals.4 Leaders may not always have authority (for instance over partner organisations), but will have to use collaborative and negotiation skills to influence others to achieve their organisational goals. In contrast, dentists work alone (apart from subordinates) with very little feedback from colleagues and other healthcare professionals. The author of this article argues that dentists do not lead, they manage. Of course, in every field some exceptional individuals exist, however, dentists face unique challenges in becoming effective leaders because many innate skills that help dentists succeed in their profession are in conflict with good leadership.

The American Dental Education Association (ADEA) reports several personality traits of dentists. ADEA suggests that dentists 'lead' 'a team of dental hygienists, technicians and assistants, but must also manage any other employees, such as the receptionist.'5 However, the author of this article would argue that this is not true leadership – this is management. A manager has subordinates, whereas, a leader has followers.6

Most dentists chose their careers because they were drawn to the perceived autonomy7,8 of the dental profession. Independence and the freedom from external control is completely in contrast to the task of a leader. A good leader cannot have autonomy because numerous complex factors affect the environment in which the leader operates. Moreover, a leader will not have direct authority over every situation she/he wishes to influence – for example, external stakeholders, competitor organisations and government regulations. Indeed, a good leader must understand and navigate the socio-political landscape and cultural climate in order to achieve their goals.

A dentist thrives in a transactional relationship environment. They tell their staff what to do and the staff gets an income to do it – a transaction. Dentists tell the patient what to do and a compliant patient gains good oral health, whereas, a non-compliant patient has oral disease. We, as dentists, conclude that non-compliance is the reason for poor outcomes. However, leaders cannot blame non-compliance for their failed ventures – a good leader must build a team that is compliant and cooperative. Research shows that non-compliant patients annoy the dentist9,10 which is further evidence that our profession does not naturally possess a rudimentary leadership skill – influence.

We conclude that if you do not comply you will not get good oral health. Compliance and non-compliance in the dental setting are simple, transactional interactions, however, great leaders operate in a transformational style.11,12This means that they know their team individually, inspire them and identify the personal value in achieving organisational goals. In this way they achieve buy-in from their team. Great leaders influence people through charisma and communication, whereas managers simply have formal authority. A great leader does not get annoyed or give up on non-compliant individuals. Great leaders must build a customised environment that allows those individuals to succeed.

Being highly detail oriented helps dentists succeed in the work that they do:5 choosing exactly the right shade for that veneer; finding exactly the right angle for orthodontic end points; and precision placement of implants into the jaw while avoiding vital structures like a nerve plexus. However, good leaders are less detail oriented, highly creative, 'big picture people.'13 While dentists must expand their view from the tooth to consider the whole person, a leader must expand their view to consider their whole organisation, competitor organisations and the population as a whole.

Although dentists work well with their dental assistant, true collaborative experiences remain elusive. Dentists don't interact directly with the rest of the healthcare profession and a fundamental objective in patient care is case control. As dentists, we are responsible for our patients. We are the experts who understand the patient, their social and medical issues and we are the oral health experts – the buck stops with us. However, in leadership, responsibility is shared and you may be one of many experts or you may not be an expert at all.

If a general dentist outsources too much of their patient's care to other providers they risk 'losing control' of the case – the patient may go elsewhere and the decisions of other providers may complicate or change your treatment plan. Delegation is also a loss of control and dentists tend to be poor delegators to their dental assistants14 and dental hygienists.15 Although dentists don't tend to delegate well, great leaders are excellent at the art of delegation. Well thought out delegation has exponential value because it enhances the confidence and commitment of the worker and reduces the workload for the leader.16,17

Outsourcing and losing control of a case has implications for loss of income and may impact outcomes too. Subsequently, dentists prefer to do most of their patients' comprehensive care. As such, they face little resistance because they oversee most of the case and do not need to address conflicting opinions in case management. In contrast, leaders face resistance all the time.18 A leader's role is extremely integrative and interactive and resistance is inevitable. Good leaders leverage the differences of opinion to facilitate the best outcomes and incorporate the best ideas. The most successful dentists do not face resistance because they control most of the care of their own patients. Moreover, when they do refer to a specialist, the specialist aims to please the generalist in order to maintain an ongoing line of referrals – feedback and resistance are unlikely except in extreme cases. Leaders of significant organisations recognise that they cannot be successful without a strong network and engagement of key stakeholders and collaborators.19 Great leaders understand the external influences, legal limitations and are able to navigate them to achieve their goals in spite of the lack of autonomy.

In dentistry we face relatively well defined problems. Caries has a straightforward solution, periapical abscess has a straightforward solution and periodontal abscess has a straightforward solution. Sometimes, these are complicated by the pre-existing medical conditions of the patient. Sometimes, atypical signs and symptoms can cause confusion through referred pain and unexpected presentations. However, for the most part problems are well defined. Leadership is an extremely complex task with many moving targets. Problems can be complex, multi-factorial and resolved through counterintuitive means. Many dentists assume profitability and know little about marketing and finance, however, a good leader needs a thorough understanding of the same. Leaders need to understand cost accounting and have the capacity to make financial data driven decisions.

Many dentists fear feedback, are not good at giving feedback20,21 and may have an equally hard time receiving it. Dentists are perfectionists22 and criticism is a threat to our perfection and excellence and, therefore, a threat to your practice. As dentists we perceive that falling short of perfection may have implications for our reputation and may even have medico-legal implications. In contrast, great leaders must have a thick skin and be very open to feedback. Without feedback and contrasting opinions the best solution will remain elusive. While hospitals move toward un-blinded, publicly available patient satisfaction data, dentists shy away from the same. Moreover, Medicare links payment incentives to patient satisfaction23 in medicine, and hospitals make outcome data publicly available while no such data are available on dentists.

Dentists are most renown for their technical ability.23 Leaders, however, are not necessarily known for technical excellence in their field. They are known for 'soft skills' like building a coalition, forming a vision and building enthusiasm and buy-in for that vision. The most highly rated skill of a good dentist is communication with the patient.23 Dentists are highly experienced and are experts at communicating one-on-one or in very small groups. However, leaders also need to communicate well to large groups. Leaders need to be strong public speakers and presenters – they should be able to communicate their vision and build buy-in from their team and organisation. While empathy and good communication are critical in the practice of dentistry, the communication skills needed to be an effective leader are immensely broad and range from listening, speaking one-on-one and addressing an audience or a board of trustees.

Literature has identified patience or tolerance as the second most critical skill of a dentist.23 How often must we endure repetitive insults from patients who denounce our career choice, or reprimand us for being five minutes late? However, tolerance is in conflict with great leadership. Leaders cannot afford to be patient and passive, in fact, they must be proactive, forward thinking and, to some degree, respectfully impatient.

Historically, society has had some concerns about the honesty of dentists.24 While the profession is generally respected, there is much documentation in scientific and social media about the reliability, agreement and honesty of dentists. However, leaders must be transparent and honest. A Forbes article rated honesty as the number one characteristic of a great leader.25

Leaders are optimists, whereas, dentists tend to be pessimists. Reports show that they are even pessimistic about the profession of dentistry and would not recommend it to their child.26 The dental profession requires us to be pessimistic – we need to warn our patients about the worst case scenario to protect our reputation, we need to warn patients about success rates of some of the most reliable treatments just for medico-legal peace of mind and we would never allow patient expectations of a complete denture to be inflated. We don't take risks and we sometimes reject intuition to go with the facts. This is because facts can be supported in a medico-legal situation but intuition cannot. Great leaders, however, must possess good intuition and must trust it.25

The purpose of this article is to draw attention to the potential conflicts that may inhibit a dentist from inherently developing good leadership skills. In an era of larger practices, staff management, complex marketing and financial decisions, dentists must study leadership skills and cannot rely on natural traits. The American Dental Association27 and various other dental organisations have formal leadership training programmes and dentists must consider these as critical learning opportunities rather than optional extras.

Conclusion

This article describes several characteristics of dentists that are in conflict with the characteristics of a great leader (Table 1).

Table 1 Characteristics of good dentists and good leaders