key: cord-0012627-if2vwl7h
authors: Ellis, Mathew; Johnson, Ilona
title: Exploring dentists' professional behaviours reported in United Kingdom newspaper media
date: 2020-08-27
journal: Br Dent J
DOI: 10.1038/s41415-020-1987-7
sha: e73e4ec2075a4c17e2f3da09141bf5c80072cd0f
doc_id: 12627
cord_uid: if2vwl7h

Aim Stories of dentists and their professional behaviours can be communicated around the world through news media. This may influence people's perceptions of dentistry and their trust in professionals. The aim of this study was to explore reports of dentists and their professional behaviours in newspaper media. Method All articles which included the term 'dentist' alongside 'professional' or 'misconduct' or 'behaviour' between 1 January 2016 and 31 October 2019 were retrieved from the ten most commonly read newspaper print media in the United Kingdom. Thematic analysis was undertaken following the application of inclusion and exclusion criteria. Results A total of 122 articles were identified. Key themes included poor practice, dishonesty and fraud, the killing of Cecil the lion, sexual misconduct, racism and crime. Many articles focused on a small number of extreme cases, labelling the dentists involved and sensationalising the stories. Reports did not reflect the majority of fitness to practise cases seen by the General Dental Council. Conclusion The sensationalist approach to the reporting of dental professional behaviours in the news may cause patients to have less trust in their dentist, and it is recommended that dentists and journalists work constructively together in the best interests of the public.

Dentistry is a recognised profession. Dental professionals registered within the United Kingdom (UK) are expected to demonstrate that they conform to the required standards of conduct, ethics and professionalism outlined in the General Dental Council (GDC) Standards for the dental team. 1 These standards predominantly relate to interactions in the dental surgery, but include an expectation that dental professionals maintain public confidence in the dental profession in both their professional and personal life. 1 The extent to which behaviours outside the dental surgery are considered professional or unprofessional are subject to considerable debate, 2,3,4,5 particularly with increasing exposure of dentists' personal lives through social media. 4, 5 For example, Cecil the lion was the best known animal in the Hwange National Park in Zimbabwe and was killed on 2 July 2015 by American trophy hunter Walter Palmer, who also happened to be a dentist. The killing provoked widespread outrage around the world and received considerable attention on mainstream and social media. Following investigations, Mr Palmer was not charged with any crime and there were no real issues with clinical care or competence. Instead, it was the moral and ethical behaviour of the dentist outside of his practice that was called into question, and this highlighted issues for professionals on how their behaviour was reported in the news and on social media. 2, 3, 4, 5 The issue of how medical professionals are portrayed in the media has been discussed among the profession for many years. While medical and scientific professionals have expressed the view that news media stories should be socially responsible, the literature suggests that news media portrayals of medical professionals often feature stories of scandals, fraud and misconduct. 2, 3, 4, 5, 6 Similarly in the medical literature, an analysis of tabloid press coverage of the General Medical Council professional misconduct cases during 1990 and 1991 found that news media providers predominantly focused on cases of sexual misconduct ahead of other areas of professional practice. Male doctors were commonly portrayed as educated professionals whose improper associations and behaviour was because of their natural sexual urges towards female patients. 7 The portrayal of dental conditions and dentistry in the news has received little attention in the literature. However, findings from a study that analysed newspaper media in relation to oral cancer 8 were similar to studies of medical professionals; focussing on the dramatic, graphic and personal. 6 The study found that stories about oral cancer in the news were often dramatised headlines with a focus Media articles of dental professional behaviours focus on a small number of extreme cases involving incidents of significant harm to patients or the public, raising public concerns about the profession.

on particular areas of behaviour, specifically celebrity and sexual behaviours, with little attention given to opportunities for saving lives through increasing public awareness of these conditions.

There is relatively little published information in relation to public views of dentists' professional behaviours. When professionalism issues arise or are identified in the UK, these are often reported to the GDC for an investigation of a dental professional's fitness to practise (FtP). These cases may or may not be heard by a GDC committee depending on the nature, seriousness and evidence relating to the case. The GDC categorises the types of FtP cases in terms of 'considerations' . The most common considerations identified in 2017 and 2018 (Table 1) were failure to provide good care, patient records and personal behaviour issues, with the majority of concerns relating to patient care. 9,10 News media is a source of public information which does report on professions and their behaviours from a lay perspective. News article content may provide an understanding of how dentists and their professional behaviours are portrayed to the public through news media.

The aim of the study was to explore the dental professional behaviour content reported in mainstream newspaper media content in the UK.

A qualitative methodological approach was used for the purpose of the study. Ten UK non-specialist national newspapers, including weekend/Sunday versions, were identified using the Audit Bureau of Circulations website, based on their circulation ( Table 2) . A search of articles published in the UK between 1 January 2016 and 31 October 2019 was undertaken including the keywords 'dentist' in combination with any of the terms 'professional' or 'misconduct' or 'behaviour' . The online database Nexis was used for the search and data retrieval.

Textual data (not image data) were retrieved from all of the articles identified by the search. All articles retrieved were read by two reviewers independently using agreed inclusion and exclusion criteria. Articles that included a dentist and their professional behaviour (including lapses or incidents which appeared to raise questions about ethics and morals) anywhere in the text (including those where this was not the main feature of the article) were included. Exclusion criteria were articles with no relevance to dentistry or professionalism. Duplicates were removed if they were in the same publication, but stories which appeared in print media which were also published online (n = 12) were counted as separate publications due to online updates, content and different sector markets.

Data were analysed thematically. 11 Themes were agreed between the two reviewers during initial analysis of the news story summaries. Coding was carried out manually line by line and data were entered into Excel. Analyses were checked by both reviewers and areas of uncertainty were resolved through discussion. Themes were developed through an ongoing process of analysis of the content; these were considered and refined, and the final themes were reached through agreement.

A total of 1,306 articles were identified through the online search. A final sample of 122 articles was achieved and a number of key themes were identified in the literature. Some articles covered more than one theme and so were included multiple times, making a total of 134 points of data. Protecting patients from risks 51 60

Not acting honestly and fairly 40 47

Training and competence 31 36

Conviction 25 25 Table 1 The most common considerations identified by the GDC in 2017 and 2018

The Times 46

The Guardian 1

The Observer 1

The Telegraph 9

The Sun 18

The Mirror 9

The Daily Mail 30

The Daily Express 4

Sunday People 2

The Star 2 

A total of 36 articles described poor clinical practices in the dental surgery. These stories related to the provision of clinical activities, to treatment or to unhygienic provision of care. Of these, seven articles described the events as part of GDC case hearings. There were two sub-themes within this category: the first was serious harm and the second was hygiene risks.

A total of 21 articles were identified in relation to serious harm. These described reports of poor clinical care resulting in serious harm to patients and often sensationalised risks to life or serious injuries in the headlines. For example: 'Left her "fighting for her life" after a trip to the dentist to remove an infected wisdom tooth caused her to develop sepsis' . 11 Language used in these articles was often dramatic or emotive, using descriptions relating to danger and fear arising from the dentists' behaviour. The implications and personal costs to individual patients arising from these injuries were often described:

'Dentist drops a steel file down patient's throat [...] As if root canal treatment was not unpleasant enough, for Vanessa Snary it became considerably worse when she needed emergency surgery to recover a 3cm-long steel tool that her dentist dropped down her throat' . 12

The second sub-theme of poor practice was hygiene risks, with 15 articles in this subtheme. These focused on poor hygiene in the dental surgery, and 14 out of the 15 articles related to two high-profile cases: Desmond D'Mello 12 and Alan Morrison. 13 While articles about serious harm often included descriptions conveying lifethreatening and harmful incidents (for example, 'hygiene horror'), articles about poor hygiene additionally labelled the dentists in relation to their behaviour; for example, '"Woeful" dentist' , 'Dirty dentist' and '"Deplorable" dentist' in the headlines. 

Twenty-two articles discussed issues with financial dishonesty. Of these, 12 focused on dentists as a professional group and 10 focused on the behaviour of individual dentists. Issues of fraudulent claims were most commonly described in relation to dentists as a professional group, with a few additional articles describing situations of unaffordable dental care or situations where patients described being misled about the cost of treatment. The most commonly reported issue was NHS fraud (nine articles), although this was often collated together as part of a more general article discussing fraud by doctors and dentists in the NHS: 'Fake patients and false claims are costing NHS £1.25bn a year' . 15 Other sub-themes included cosmetic dentistry, perceived excessive cost of dentistry and unnecessary treatment, with articles alluding to greed on the part of the dentists involved:

'Man facing eight root canals and a $100,000 dental bill scores a "Tom Cruise smile" for a fraction of the price after travelling to India' . 16 Cecil the lion and the unethical dentist Twenty-two articles discussed the case of an American dentist in the killing of Cecil the lion. These articles eluded to unethical behaviours and cited the case in a way that suggested that, ethically, the dentist who killed Cecil the Lion should not have done so because of his professional position. Articles included: the dentist who killed Cecil (three articles), the killing of Cecil's son by a different hunter in 2017 (six articles), killing of other unrelated animals by trophy hunters (four articles) and trophy hunting in general (nine articles). One of the most common features in the articles was animal suffering, which was contrasted with the moral and ethical expectations placed upon a dentist: '[...] shot with a bow and arrow by Walter Palmer, an American dentist, and took 40 hours to die' . 17 

Fourteen articles reported sexual misconduct, including serious sexual offences, alleged sexual harassment and inappropriate sexually motivated behaviours. These often described the allegations and sexual behaviours in detail:

' A dental lecturer found to have repeatedly had sex in his office was kicked out of his profession yesterday [...] A mystery woman's visits "coincided with noises of sexual activity", a General Dental Council committee in London heard. Dr High was struck off the dentists' register after all seven misconduct charges against him were found proved' . 18 Quotes from the GDC hearing that were particularly eye-catching were also used in these articles:

'Dentist is suspended for six months for misconduct over "creepy" and inappropriate behaviour towards two young dental nurses including stroking their hair "for sexual gratification"' . 19 Articles relating to sexual misconduct commonly labelled the dentist in a way similar to articles discussing harm:

'PERVERT DENTIST JOB OK; Let-off from judges. A SEX pest dentist who harassed female staff and threatened to put nude photos of one on the internet has kept his job' . 20 Violence and racism Fourteen articles described dentists in relation to violent or racist behaviour. As with other themes, many of these articles used names to label to the dentist; for example, 'dentist conman' and 'baby murderer' . Three described dentists as victims of violent crime or racism, and nine featured dentists as perpetrators or suspects:

' A Sheffield dentist has been struck off the professional register amid accusations he punched a patient in the face' . 21 A further two described dentists' involvement in uncovering crimes:

'She told police about the abuse after a dentist noticed damage to her mouth following one of Sweeney's brutal attacks' . 22 Scope of practice Ten articles reported on issues relating to the scope of practice. The most common was nondentists providing dental care (five articles), which predominantly involved illegal tooth whitening, and a further two articles described unqualified individuals acting as dentists. The underlying narrative for all of these articles related to dentistry as a lucrative profession and being used for 'get-rich-quick schemes': 'Fake dentist who performed root canals, crowns and extractions on unsuspecting patients is ordered to pay more than $60,000' . 23 Some of the narratives highlighted the risks of cheap and inappropriately provided dentistry:

'WARNING ON TOOTH COWBOYS [...] Standards have warned against non-dental professionals offering dangerous "Hollywood Smile" teeth whitening on Britain's high streets' . 24 The other sub-theme related to dentists being accused of working beyond their ability (two articles):

'Cosmetic dentistry is not a real specialism. Most cosmetic dentists are simply general dental practitioners [...] "gold rush" of dentists setting up lucrative cosmetic practices with no training [...]' . 25 As in previous themes, these articles would commonly choose an emotive label for the dentists for dramatic effect, such as 'tooth cowboys' . 24 

Six articles described incidents where alcohol or drugs were involved. The fact that a dentist was involved was used to add an increased sense of shock or surprise in relation to the behaviours described.

Of these, four articles focused on the death of dentist Helen Nicholl, who committed suicide in 2015 following a violent argument with her husband, who was also a dentist. This was a tragic case which involved the use of alcohol and prescription medications for anxiety and depression:

'Desperately lonely life of tragic dentist whose kids called her "scum"; FAMILY ROWS AND RIFTS THAT PLAGUED SUICIDE MUM HELEN' . 26 Of the remaining articles, one described the use of alcohol and drugs by a dentist's partner as a contributory factor in a violent crime carried out by the dentist. The other article described an American dentist and the diary he kept of his experience of the four-day Sex Island festival in Venezuela, describing orgies and taking cocaine: '[Dentist] paid £4,600 for orgies with multiple hookers and unlimited drugs' . 27 

Six articles discussed dentists as the perpetrators of crimes and serious misconduct in works of fiction and video games. While these did not involve real people, these stories contributed towards the public perception of professionalism among dentists. All of the portrayals of dentists were negative.

Four articles related to dentists failing to communicate appropriately with patients. One article criticised dentists who use technical terms such as amalgam, composite and rubber dam, rather than plain English. A second article highlighted complaints to the GDC about poor English among EU graduate dentists practising in the UK.

One article reported that the NHS was having to apologise to patients who complained that they were 'fat-shamed' by healthcare professionals including dentists; this contrasted with another article about dentists failing to check whether patients' weight was safe for the dental chair: • '[...] another woman was offended when a dentist suggested her son was too large to fit in his chair' 28 • 'Dentists are warned: Don't treat obese patients or you may be sued' . 29

This study found that the majority of reports in the news media related to poor practice, financial impropriety, Cecil the lion, sexual misconduct, and violence and racism. Many of these articles focused on a small number of high-profile national or international cases, and a number related to GDC or court cases. Therefore, while poor practice is indeed one of the most commonly recorded FtP issues, 9, 10 it appears that only a small proportion of these cases attract media attention. Similarly, criminal convictions were uncommon, but attracted a disproportionate level of attention, which may relate to a greater level of newsworthiness arising from the risk and drama. Unhygienic dentists were widely reported, but most of the articles related to just two cases where there were wide-ranging public health implications. In one of the main cases, involving Desmond D'Mello, 30 22 ,000 patients were reportedly recalled and 4,526 were screened for blood-borne viruses, with five found to have hepatitis C. In another high-profile case, that of Mr Morrison, 31 2,250 patients were screened for blood-borne viruses and four were found to have hepatitis C. As a result, 800 patients took legal action, which made this the largest class action in Scottish legal history.

Articles about poor clinical practices often sensationalised risks of infection. These findings align with the wider literature in relation to risk reporting, which suggests that the public can be more concerned about uncommon serious risks than commonly occurring, less serious risks. 32 Furthermore, articles about media coverage of other health topics (for example, pandemic influenza) have highlighted the conflicts that can arise in relation to sensationalism, scaremongering and public responsibility, 33 leading to questions about whether this style of reporting on public health topics does more harm than good. 34 It is considered a key role of the media to raise questions, highlight public concerns and to generate action, but there is no consensus on how to do this in a way that does not cause undue harm though fear. 35 The second most common theme in the news was dentists' dishonesty for financial gain. The issues highlighted contrasted with ethical concepts of the dentist as a good person, 36 able to make moral decisions. The costs of providing dental treatment feature significantly in the GDC Standards for the dental team 1 and most dental care involves payments. These costs can generate ethical challenges, particularly when patients are not willing or able to pay, or where the remuneration for treatment is less than the cost of providing care. 37, 38 Dentists have highlighted particular ethical dilemmas in relation to dental contract payment and its reforms in the UK. 39, 40 However, the most common focus of articles was financial fraud, most often focused on dentists as a group. This is of particular concern as this could have a much wider impact on public confidence in the profession than poor behaviour limited to a few individuals, and reinforces the stereotype of dentists as greedy. The challenges for dentists in providing care were rarely considered, reflecting a sense of expectation that adverse outcomes should not occur and a dentist should behave in a way that demonstrates moral and ethical behaviour irrespective of any challenges.

The third most commonly reported theme of Cecil the lion and the unethical dentist highlighted expectations of morally appropriate behaviour beyond the confines of the dental surgery. Further trophy killing reports in the news commonly referred back to this case, always reporting the fact that Mr Palmer was a dentist. Given that the profession of dentistry is irrelevant to the act of killing Cecil, it is debatable whether an amateur hunter's profession would be mentioned at all, were they not a dentist. A key point raised in the articles was that he was deemed to have caused unnecessary suffering to the animal for his own enjoyment and pleasure, and that this was at odds with his professional position. Similarly, articles about violence, racism and substance abuse commonly juxtaposed acts deemed to be offensive and inappropriate with the individual's role as a dentist.

Within the professional literature, there has been a debate about the extent to which a dentist's professionalism includes their personal life. 4, 41 While there is a view from some within the dental profession that this should not be included, 41 the GDC Standards for the dental team and the media findings in this study appear to suggest that professionalism is considered to extend into dentists' personal lives. 1 The present study findings indicate an expectation in media coverage that dentists should demonstrate a higher standard of behaviour in their personal lives than the wider public, to the extent that if a dentist was remotely connected to an event, their profession was used to add surprise or sensation to the article. Similar to findings in previous studies, stories also used labels and puns to highlight issues. 8 Media coverage was often intense, highlighting rare but serious incidences of infection risk, sexualised behaviours, crimes and unethical behaviour.

It is interesting to note that, of all the articles included, only two reported dental professional behaviours in a positive light; in safeguarding and in helping to uncover a crime. One of the reasons for this may have been the limitations of the search, as the search terms may have influenced the retrieval of more positive content. However, the findings do reflect other news reporting, as there is a tendency to ignore the good work which is done every day and instead to focus on the minority of bad cases.

Newspapers often focus on, and sensationalise dramatic and unusual cases of professional behaviour. This is similar to the medical news coverage, 33, 34 and may cause unnecessary concern and additional anxiety among patients. Dental professional bodies should campaign for more balanced coverage of dentists and dental professionalism within news media, and continue to promote the good work of the profession. 34, 35 

Social media: Professionalism

Dentistry's social contract and the loss of professionalism

Social media use, attitudes, behaviours and perceptions of online professionalism among dental students

Social media and dentistry: some reflections on eprofessionalism

An uneasy relationship: the tensions between medicine and the media

Sexy docs' and 'busty blondes': press coverage of professional misconduct cases brought before the

Oral cancer: exploring the stories in United Kingdom newspaper articles

General Dental Council. Annual Report and Accounts

Artist, 25, developed sepsis after having an infected wisdom tooth removed

Dentist drops a steel file down patient's throat. The Times (London)

Woeful' dentist banned for using dirty tools

Dentist struck off after her dog bit inspector

Fake patients and false claims are costing NHS £1.25bn a year. The Daily Telegraph

Man facing eight root canals and a $100,000 dental bill scores a 'Tom Cruise smile' for a fraction of the price after travelling to India

Oxford University researchers accuse game hunters of lying about how they shot son of Cecil the lion

Dentist's romp axe. The Sun (London)

Dentist is suspended for six months for misconduct over 'creepy' and inappropriate behaviour towards two young dental nurses including stroking their hair 'for sexual gratification

Let-off from judges

Sheffield dentist accused of punching patient in the face. The Star (Sheffield)

I lived with serial killer for 3 years and knew I'd be his next victim when I found his murder kit under the bed

Fake dentist who performed root canals, crowns and extractions on unsuspecting patients is ordered to pay more than $60,000

RAP Brits warned over tooth cowboys offering dangerous 'Hollywood Smiles' whitening treatments on the high street

Patients left with ruined teeth as cosmetic dentists get rich quick

HER KIDS CALLED HER SCUM' The desperately lonely life of tragic suicide dentist 'torn apart by family rifts and fighting

ORGY PARADISE Sex Island guest's diary reveals romps with 100 women and randy tourists PASSING OUT from too much sex

NHS is forced to apologise to hundreds of obese Britons 'fat-shamed' by health professionals

Union warns dentists NOT to treat morbidly obese patients over fears they could break clinic chairs leading to a lawsuit

General Dental Council. Outcomes and appeals list

Availability: A heuristic for judging frequency and probability

Journalists' views about reporting avian influenza and a potential pandemic: a qualitative study

Do media help or harm public health?

Media coverage of health issues and how to work more effectively with journalists: a qualitative study

A virtue ethics approach to moral dilemmas in medicine

The Economics of Dental Care

Introducing high-cost health care to patients: dentists' accounts of offering dental implant treatment

Challenges facing NHS dental contract reforms: Pilot exit

Job satisfaction of dental practitioners before and after a change in incentives and governance: a longitudinal study

Should 'fitness to practise' include safeguarding the reputation of the profession?