The Clock of Life

The Clock of Life by Robert H Smith

The clock of life is wound but once
And no man has the power
To tell just where the hands will stop,
At late or early hour.

To lose one’s wealth is sad indeed,
To lose one’s health is more.
To lose one’s soul is such a loss
As no man can restore.

The present only is our own.
Live, love, toil with a will.
Place no faith in ‘tomorrow’
For the clock may then be still

Hours down. Productivity up. Nothing new.

Sculpture of a Ford car in his father’s village in West Cork.

“Reduce your hours and watch your productivity increase.” I tell my clients that they need to focus on the the three Es by becoming, “Efficient, Effective and Economic.” This does not mean cutting corners or scrimping to save, rather ensuring that you are doing the best you can for only as long as you need – and no longer. Most dentists spend far too much time doing work that is undervalued, under rewarded and ineffective.

When my team & I stopped working 5 clinical days per week, our income and profits rose and team morale increased. Unfortunately there is still a macho thing about being booked “X” weeks ahead, it’s more likely to kill you than make you happy.

My daily calendar tells me that today in 1926 Henry Ford introduced the 5 day, 40 hour working week. I have an interest in Ford, not least because his father was born a few miles from where I am writing this in West Cork and my grandfather had some involvement with the Ford factory in Cork. I wondered how the hours change came about and why we seem to have stuck there or, in some cases, moved backwards in 94 years.

It seemed that Ford’s decision was one of several that put the company’s workers first. In 1914 with a background of unemployment he increased wages from $2.34 to $5 for a nine hour day. This move, doubling the industry norm, shocked many who said it would not succeed. Instead it was “a stroke of brilliance”, it boosted productivity and helped build a sense of company loyalty and pride.

Then came the reduction from 6 to 5 working days, a decision originally made four years earlier, justified by Henry’s son, Edsel Ford, “Every man needs more than one day a week for rest and recreation….The Ford Company always has sought to promote an ideal home life for its employees. We believe that in order to live properly every man should have more time to spend with his family.”

Henry said, “It is high time to rid ourselves of the notion that leisure for workmen is either ‘lost time’ or a class privilege.”

Ford also saw a bigger picture. Give people Saturday off and they can shop and have leisure, thus spending the money they are earning.

…and we think the “gig economy” is progress?

The Monday Morning Quote #501

“This is a very important lesson. You must never confuse faith that you will prevail in the end – which you can never afford to lose – with the discipline to confront the most brutal facts of your current reality, whatever they might be.”

Admiral James Stockdale

Yerkes-Dodson is still relevant – if you want to enjoy your clinical career

Why should a “law” described first in 1908 be relevant to everyday Dentistry (and more)?

Robert Yerkes and John Dillingham Dodson described their tests with rats that could be encouraged to complete a maze when stimulated with slight electrical shocks. When the strength of the shocks was increased however the rats just ran about looking for an escape. They concluded that arousal levels helped to focus attention and motivation on the task at hand but only up to an optimum point and after that point fatigue appeared and performance declined.

Research has found that different tasks require different levels of arousal for optimal performance. For example, difficult or intellectually demanding tasks may require a lower level of arousal (to facilitate concentration), whereas tasks demanding stamina or persistence may be performed better with higher levels of arousal (to increase motivation).

The first image shows the classic inverted ‘U’ shape of a difficult task (placing implants, molar endo, treating some children are examples that come to mind). It also shows a continuation without decline of more simple tasks which can be maintained for longer without reaching a point influenced by fatigue (examinations, routine restorations on well adjusted patients).

 

 

The second image shows the typical “stress curve” where performance takes a while to peak if we are under too little stress, then goes through a short period of optimum stress before reaching too much and heading down through exhaustion to burn out.

The reason that I have written about this is that we need to look at the time periods that these curves represent from the short (an hour say) to long (months or even years). There are different challenges that dentists face with differing solutions.

Firstly of course there is the fatigue that comes from trying to do too much challenging work in a short period of time. This results in high stress levels and possibly poor performance on a daily basis. Often there are time management issues where we are obliged to match our performance to the patients availability. This can see a clinician “coasting” by dealing with the relatively straightforward whilst at their peak in terms of readiness and responsiveness but then having to find reserves of energy when the patient “demands” treatment at later times in the day. I have never understood why dentists are reluctant to tell the patient exactly when and why they would like to see them. My own experience in a practice with large numbers of children was to insist on seeing under 11s for any treatment (examinations excepted) first thing in the morning. For the most part when people have reasons explained to them and can understand that it is for their benefit then they will comply with your wishes.

Also to consider are the long term problems of fatigue that arise from the day after day, just doing it without time off. Even in the best time managed (at a relatively micro level) practice if there is often not enough time spent away to unwind, recharge the batteries and recover, then burn out will creep up on you. The prodromal signs are a lack of efficiency and, more importantly, effectiveness.

Dentistry is still a macho occupation for many who seem to get a perverse enjoyment from overwork. It’s sad but true that for many there is an opportunity to build the life they want but put obstacles in their own way as if frightened of taking control.

Time management on both micro and macro levels is hugely important, ignore it at your peril. Get help if you need it.

Julian Tudor-Hart RIP

I was sad to hear of the death of Julian Tudor-Hart recently. I quote from his obituaries:

A visionary general practitioner (GP) who spent his career practising what he preached, Julian Tudor Hart is best known as the author of the inverse care law: “The availability of good medical care tends to vary inversely with the need for it in the population served.” Like Karl Marx, his guiding inspiration, Tudor Hart believed that it was not enough to interpret the world in various ways; the point was to change it.

“He was the first GP to measure the blood pressure of all his patients”, “At the time, hypertension was often thought of as a condition that had to be managed by hospital specialists”. “Julian was a major force in ensuring that it became embedded in primary care.” “When in 1990 he published the results of 25 years of what he’d been doing compared to a neighbouring practice, he showed that mortality was down by about 30%”. This, Watt (Professor Graham Watt, Honorary Senior Research Fellow in Glasgow University’s Institute of Health & Wellbeing) believes, was attributable to a number of interventions besides blood pressure measurements. “The main thing, I think, was that he was providing unconditional personalised continuity of care for all his patients

Writing in “A New Kind of Doctor” in 1988 he described what he called “Anticipatory Care” as “Professionally, the most satisfying and exciting things have been the events that have not happened: no strokes, no coronary heart attacks, no complications or diabetes, no kidney failure with dialysis or transplant. This is the real stuff of primary medical care.”

Obituaries HERE, HERE & HERE

The Monday Morning Quote #500

“Difference is the essence of humanity. Difference is an accident of birth, and it should therefore never be the source of hatred or conflict. The answer to difference is to respect it. Therein lies a most fundamental principle of peace: respect for diversity.”

John Hume

The 500th Monday Morning Quote and a very personal one.

HPV vaccination – still too slow

I have written before about HPV vaccination HERE, HERE, HERE, & HERE. I thought all was going well however this article in the Lancet has made me realise there’s a way to go.

Data from Public Health England highlight how the UK’s national cervical cancer vaccination programme has greatly reduced the prevalence of human papillomavirus (HPV) in young women, providing encouragement for a future reduction in cervical cancer mortality. HPV, however, is implicated in other cancers in both sexes (eg, oropharyngeal and anal cancer), and HPV infection also causes genital warts in both sexes. HPV-related oropharyngeal cancer is the cancer with the fastest growing incidence in the UK, and is soon to become more common than cervical cancer in the USA. Given the results of the Public Health England study, a gender-neutral vaccination programme would provide substantial protection for the overall UK population.
Boys and girls are vaccinated as part of a universal strategy in an increasing number of countries, which now includes Australia, Austria, Bermuda, Brazil, Canada, Croatia, Germany, Israel, Italy, Lichtenstein, New Zealand, Serbia, and the USA. However, despite mounting evidence and support from clinical, scientific, and patient advocacy communities, the UK has been slow to move towards universal HPV vaccination. The Joint Committee on Vaccination and Immunisation (JCVI) has been considering the merit of a universal vaccination strategy since 2013, but issues such as putative herd immunity and cost-effectiveness were cited as reasons to postpone vaccination of adolescent boys.
Herd immunity for boys will only occur in areas where rates of female vaccination are high (≥80%). Substantial reductions in female vaccination rates have occurred in Denmark, Japan, and, most recently, Ireland (51% uptake), although a high-profile government campaign led to vaccination rates in Ireland increasing to more than 60%. Uptake in the UK varies substantially by region (eg, a 48% uptake in Stockton-on-Tees compared with a UK average of 83%). Herd protection will not protect men who have sex abroad or with older unvaccinated women.
Our findings and those of others have indicated that universal vaccination can deliver substantial health economic benefits. An analysis also indicates that the mathematical modelling studies underpinning policy recommendations regarding universal HPV vaccination might have been flawed. The additional cost of vaccinating boys in the UK would be £20–22 million annually at most (<0·02% of the UK National Health Service’s annual budget). However, this cost is offset by the annual costs of treating genital warts (about £58·5 million), HPV-related oropharyngeal cancer (>£21 million), and anal cancer (about £7 million). Wider economic benefits (increased productivity and earnings, enhanced tax revenue) would also ensue. Thus, universal vaccination can save lives and yield economic savings for our health-care system.
The mounting evidence has led to the JCVI finally recommending a universal HPV vaccination strategy. Although the Departments of Health in England, Scotland, and Wales have now indicated their willingness to vaccinate boys and girls on the basis of the JCVI recommendation, the Department of Health in Northern Ireland has been disappointingly silent on the issue to date. It is crucial that this decision is implemented rapidly and equitably across the UK to spare the approximately 400 000 adolescent boys each year who are left unprotected against the serious life-threatening and health-debilitating diseases that result from HPV infection.
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