According to medical educator Timothy P. Bright, PhD, stress is “the basic confusion created when one’s mind overrides the body’s desire to choke the living daylights out of some jerk who deserves it.” A more conventional definition is that stress is what happens when perceived threats chronically activate the body’s “fight or flight” response.
However it is defined, stress is an important health concern for today’s physicians, agreed experts attending the Third International Conference on Physician Health, sponsored by the American Medical Association, Canadian Medical Association, Federation of State Medical Boards, and Federation of Medical Licensing Authorities of Canada.
Stress Symptoms
The very characteristics society values in physicians, because they make for better doctors, also make physicians unusually susceptible to the negative effects of stress.
According to psychiatrist Roy W. Minnesinger, MD, most physicians are “compulsive.” This element of compulsives is manifested in traits such as attention to detail, hyperconscientiousness, a deep commitment to the patient and the ability to absorb and contain anger and other negative feelings.
In addition, physicians tend to be perfectionists, workaholics, and markedly guilt-prone, noted Dr. Menninger. “In other words,” he said, “the average doctor doesn’t get much fun out of life.” Physicians also tend to be so self-sacrificing that they feel guilty about attention to their own needs. As a result, they usually are the last to admit that they are suffering from stress.
Symptoms of stress may include physical reactions such as cardiovascular, gastrointestinal and respiratory problems. But stress also can manifest itself in other ways, which are “often more obvious to others” than to the doctors themselves, Dr. Menninger said.
People under stress often exaggerate normal behaviors – for example, working even longer hours. They also tend to “become a caricature of themselves: Quiet people become quieter, and loners become more isolated,” Dr. Menninger noted. Other behavioral changes may include sleep disturbances, withdrawal from colleagues and friends, decreased work effectiveness (i.e. unaccustomed difficulty managing patients or fear of referring patients) or increased drug and alcohol use.
Emotional reactions can include anxiety (tension, nervousness, jumpiness, inability to relax) hostility (irascibility, anger at minor things), scapegoating (blaming others, fault-finding, being critical or hard to please), and depression. Markedly increased family tensions also are common. These include the appearance of stress symptoms in other family members, fewer stress-free conversations, more fights, fewer shared satisfactions and a tendency by both spouses to become easily upset or angry.
“Frequently,” said Dr. Menninger, “any or all of the above symptoms are accompanied by denial from the physician that anything is the matter.”
Intimacy as a Stress Buffer
Physicians often use intimate relationships as a buffer against the negative effects of stress. However, Walton E. Byrd, MD, a clinical psychologist, believes that certain behaviors, such as compulsivity and perfectionism, tend to undermine many doctors’ intimate relationships.
A particular problem for physician relationships is what Dr. Byrd dubs as the “psychology of postponement.” Beginning in medical school, physicians put their time and effort into medicine, while important relationships are neglected. By the time physicians do find time for their marriages, their spouses are angry and resentful, and both parties are lonely and isolated.
Doctors with troubled marriages should dedicate time to getting those important relationships back on track. “Physicians should set aside time each day to talk about themselves,” Dr. Byrd said. “They should block out time once a week to go out to dinner or go to a movie, and should try to get away three or four weekends a year to go on vacation with their spouse.”
A New Way to Think
All people are not equally stressed by the same environment. The difference often lies in how each person thinks about a potentially stressful experience. “Stress is a reaction to a perceived threat,” said Dr. Brigham. “What you’re telling yourself about what is happening may be what makes it seem like a threat.”
Physicians tend to develop habitual ways of reacting to such threats. These habits, which often open physicians up to increased vulnerability, may include:
- Deficiency-focusing– the habit of focusing on the negative at the expense of the positive. No matter how things are going, this habit involves looking for the thing going wrong, rather than the thing going right.
- Necessitating – the belief that we have to do something rather than that we have a choice in doing it. Every request is translated into a demand, and any failure to live up to demands on the self is expected to result in calamity.
- Low skill recognition– the tendency not to recognize the role of the one’s abilities and successes. Everything positive is attributed to something external, such as luck or another person. If a person with this habit finds a task easy, he or she thinks that it is not worth doing.
“Fortunately, these habits are not ingrained personality patterns and can be changed,” said Dr. Brigham. Although it is easier to change these patterns with expert help, anyone can learn to challenge them. He recommends:
- When deficiency-focusing, ask, “What is right in this situation and how can the obstacles be overcome?” The goal is not to negate or pass off mistakes, but to gain perspectives on them by placing them in the proper context.
- When necessitating, ask, “What can realistically happen if I don’t do this?” or “Is there room for negotiation?”
- For low skill recognition, ask, “What did I contribute and what abilities did I show?” The goal is not to ignore limitations, but to recognize growing skills and abilities so one can gain confidence and self-esteem.
Stress-reducing Techniques
Edward Messner, MD, a clinical professor and author of Resilience Enhancement for the Resident Physician, has outlined some stress-coping techniques. He emphasized that stress-reducing approaches are useful for practicing physicians and residents alike, and urged doctors to select the technique that best suits their situation. Dr. Messner’s stress busters include:
- Inner Dialogue: Imagine a conversation about the stressful situation. One speaker is the distressed part of yourself, and the other is your calm, mature side. By playing out this imaginary conversation, you will help stabilize emotional reactions and neutralize feelings of isolation.
- Mental Rehearsal: Imagine, in advance, your response to a stressful situation. For example, when anticipating the encounter with the family of a dying patient, try and imagine the conversation that might ensue, playing out different versions of the same confrontation. This exercise may ease difficult interactions and protect you from responding inappropriately.
- Expressive Fantasies: Imagine stress-relieving actions that you would never carry out. “It is important to keep in mind that these scenes are imaginary, not to be put into action,” said Dr. Messner.
Many people also find that they can manage stress through physical activity. Activities such as stretching, isometrics or running up and down stairs can be effective stress relievers and release a great deal of pent up tension.
Relaxation techniques also can release feelings of stress and counter stress-induced insomnia, and may include:
- Autohypnosis – repeat to yourself a little speech suggesting that you are relaxing or falling asleep. An alternative is to close your eyes and systematically relax different parts of the body. You also can give yourself the suggestion that when you wake you’ll feel alert and refreshed.
- Progressive muscle relaxation – close your eyes and systematically relax your body. Some people do this best by imagining each segment of the body, others by imagining that a wave of relaxation is flowing over the body.
- Meditation – focus on your breathing, thinking about each expiration. Before long, your respiration’s will slow down and deepen, mimicking those of sleep. It also is possible to repeat the same phrases silently, over and over.
For those physicians who cannot handle stress on their own, Dr. Messner urged them to seek psychiatric care. He said the message is simple: “Recognize the stress and admit it’s there. Know that there are accepted ways to reduce your reaction to stress and, if you can’t handle it, don’t hesitate to ask for help.”
This article was originally published in the October 24/31, 1994 issue of American Medical News, the weekly newspaper of the American Medical Association. It is published in the AANS Bulletin by permission of the author, Flora Johnson Skelly.