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H. R. Chapman, S. Y. Chipchase and R. Bretherton British Dental Journal 2015;219: E8

Editor's summary

Readers with a longer memory, which is a polite way to say older readers, may remember that until about 10 years ago I used to write a regular column in the BDJ entitled 'View from the chair', which was intended to be humorous and to take a wry sideways look at dentistry. At a BDA conference a colleague who I didn't know approached me, introduced himself and asked if I had ever visited his practice. I replied that I didn't think I ever had and wondered why he thought so. Very flatteringly he explained that because that which I wrote was so close to everything that went on in his practice he assumed I must have a near constant presence.

I recalled the incident as I read through this paper when it was initially submitted and mused on it in the interim. I am also now tempted to remark that it would have been quite impossible to have written from imagination the comments of the dentists who participated in this qualitative research because they are so painfully real and sometimes poignant in their insight.

Most of us in dentistry would agree with the assertion that one needs to be a particular sort of person and personality in order to want to become a dentist and indeed to stay within the profession. That personality requires a tremendous resilience in order to cope with the wide range of situations, team members, patients, clinical decision making and business planning that the job demands; not just requires but demands.

The ability to cope is central to the line of enquiry of this and its associated papers emanating from the study and the authors are to be congratulated for tackling this difficult topic in an innovative and yet still sensitive way. The results, as well as making genuinely fascinating reading of themselves, give us some sense of the emotional capacity we have and also of the support and help we seek, and sometimes do not receive. In turn this may lead to establishing more and better routes to help each of us at various stages of our careers and lives. Reading these through one empathises again and again with the comments and I might be tempted to ask if the researchers had actually visited your practice and talked to you without you realising it.

The full paper can be accessed from the BDJ website ( www.bdj.co.uk ), under 'Research' in the table of contents for Volume 219 issue 9.

Stephen Hancocks

Editor-in-Chief

Author questions and answers

Why did you undertake this research?

This research looks in detail at the stressors that dentists face on a daily basis in practice. This second article in our short series focuses on the ways these stressors affect the dentists and how they respond. Previously this has been explored using questionnaires which are not terribly helpful as they do not allow responses to varying situations and emotions to be differentiated. Nor do responses to questionnaires highlight the transactional nature of coping. The detailed interviews help us to understand how dentists think, as well as to see their behavioural responses. This is important if we are to better understand how to help dentists cope effectively with the stressors of practice, many of which cannot be changed. Coping involves taking clinical decisions and we also sought to explore dentists' clinical decision-making and how it was affected by emotions as there has been no previous research in this area.

What would you like to do next in this area to follow on from this work?

The variety of problems encountered by the dentists suggests that a broad armamentarium of coping skills would be beneficial in improving dentists' coping. Dentists' lack of recognition that emotionally difficult situations had an impact on their clinical decision-making, even when they could describe just how it was affected, suggests that further education regarding the impact of emotions in the surgery would help dentists and patients alike. The findings from this research have already been incorporated into a coping skills and decision-making package for dentists, which we are hoping to further develop in the future.

Commentary

This report by Chapman and colleagues is important on at least two counts. Firstly, it adopts a methodology which has the ability to unravel some complex processes in dental clinicians. The use of a semi-structured interview to provide some necessary flexibility for the dentist to tell their story, from their perspective, is a technique that suits the purpose of this sensitive investigation. The use of a pencil-and-paper distress rating or standardised coping questionnaire would have struggled to provide a profile that could demonstrate the range of options and behavioural responses in the course of routine oral assessment and treatment. Hence, the authors have successfully collected some revealing consequences of emotionally charged situations.

A second point of note for this interview study is the identification of a set of emotions that clinicians experience when working with patients. The study suggests that the majority of the emotions raised are negative and required some probing to receive acknowledgement. The norm for discussion of this topic by dentists is denial. So it is helpful that the investigators have persisted to focus on the dentists' reactions, especially on the emotions themselves, and the coping and behavioural responses. Not only are these emotions expressed by the dentists, but the consequences and ways that these individuals attempt to cope with raised levels of emotional experience are also recounted.

Of issue in the report is the recognition that emotions are very often experienced by dentists in front of their patients, but they recognise that they cannot reveal them. They, therefore, need to be subsumed in some way. This process, as raised by the authors, is not psychologically sustainable in the long term without some compromise of mental well-being in the dentist. A fascinating conjecture raised by the report is that there may be micro-behavioural indicators that patients spot in their dentist's presentation which cannot be disguised by the dentist. It is this area that has been traditionally ignored in research studies and which this commentator would strongly encourage.

The focused attention on a detailed system of coding of the video interaction between patient, dentist and nurse has previously been reported regarding emotional exchanges in routine dental care.1 It is this field of endeavour that might be considered the next step to analyse and inform the profession, training centres and notably dental schools of the practical tools of communication in response to emotionally charged situations. This field can be studied in exquisite detail to perform detailed reports and provide many examples of successful strategies in the management of patients in practice settings.