Managing stress as a doctor
What is it about doctors that makes them vulnerable to poorly managing their own health?
Our research at the Doctors for Doctors Unit shows that only one in three doctors would see their GP when unwell, despite almost all being registered with one (which is often simply required for work, insurance and so on). One in eight doctors reported that they use alcohol or drugs to help them cope with work and ill health, about one in four reported knowing of colleagues who do so.
It is probably a combination of factors leading to such problems: the conscientious personalities of doctors, the demands of the job, and the culture and systems around doctors health.
There are traits that typically feature in a doctor's profile that might make us good at being doctors, but not necessarily at looking after ourselves. We are obsessive and perfectionist, overly conscientious, and we seek approval. Doctors need to be in control, but may harbour chronic self-doubt. We also tend to dislike praise and delay gratification or the rewards from the job.
The very definition of the job also creates a fine line that doctors walk. To be a good doctor, one needs to be involved with patients (capable of empathy and humanity); yet to remain objective and survive emotionally, one needs to be detached from their pain and suffering. And higher levels of self-criticism are associated with high rates of depression; yet doctors need to be obsessional and self-critical in order to avoid mishaps. The very traits that are necessary for good patient care may not be good for the doctor's health.
Demands of the job
But there are also external factors that cause doctors to burn out. We are giving all day (and night) emotionally, and dealing with physical and emotional distress but who cares for us? For GPs in particular, there is isolation, both psychologically and physically. Doctors are also practising intensively at front line. Long hours lead to poor family relationships/support. Added to all this there is:
* A lack of feedback (except in the form of complaints!);
* Perceived threat of, for example, violence, complaints;
* Insecurity (poor support from management; and NHS reorganisation);
Comments doctors have given us sum up how there is much collusion allowing the health effects of all these stresses to go unchecked - that doctors are not supposed to be ill, everyone expects a doctor to get on with it and cure himself, doctors with health problems are seen as potential problems and I don't think the avenues are clear enough. There is enormous pressure on doctors not to give in to ill health.
So how do doctors know when these three factors - themselves, the job, and the culture around them have conspired to start causing damage, and what can they do about it?
The symptoms of burn out are identifiable in four areas: emotional, cognitive, behavioural and physical.
Loss of humour;
Depressed mood, apathy;
Feelings of failure/guilt/blame.
Rigidity/resistance to change;
Ruminations (of leaving, revenge, and so on).
Work avoidance (absenteeism, clock-watching, and so on);
Diminished personal conduct with clients/colleagues;
Acting out (alcohol/drugs/affairs/shopping, and so on).
Increased minor illnesses (headache, backache, and so on).
Many of the ways in which we can help ourselves will read as common sense and are often not too difficult First and foremost, register with a GP before any problem presents itself. When there are stresses, share problems with family, friends, and colleagues and admit vulnerability. You are a human-being like any of your patients. Set boundaries and make space for yourself; learn to say NO. Try to build in some protection to your spare time so that it doesnt get eaten into. And seek help early if you do develop problems that need further management, and consider options including psychotherapy or counselling.
If you are feel that you are getting symptoms of burn out, keeping a stress diary for just a week can help with identifying the stressors and doing something about preventing further ill effects. Divide the day into hours and record events occurring in each hour. Rate events on a scale of one to ten on two parallel charts one for how stressful the event was and another for how much benefit that same event provided you. After a week, reflect on your ratings and try to alter those events that are causing you high stress for low value. The process of keeping a diary means you will also be paying some attention to time management, which can also help against stress. An example of a time management tool that is quick and easy to use can be found at this web page from Bristol GP solutions [http://www.bristolgpsolutions.org.uk/h4.htm ].
Applying a CBT approach to stressful events can help you identify and manage problems too, simply by thinking about your reactions to situations and asking these sorts of questions:
- Was it stressful and how?
- What was I thinking and how did I react?
- What was the outcome?
- How could I have reacted differently?
- What changes could I make?
Identify your negative thoughts review them rationally and challenge them. Counter what have become automatic negative thoughts - with positive alternatives. Sometimes it can also be helpful to try and see the point of view of those with whom you are in conflict.
A final note is that one of the factors that need not necessarily be out of your control is your colleagues and your particular work set up. GPs in particular should place some importance on finding the right practice or partners as far as possible.
In summary, there is much you are in control of yourself to prevent problems caused by the pressures of the profession. Your personality, what being a doctor demands, and the culture around you are three factors that you can recognise and manage too.
Dr Michael Peters, Head of the Doctors for Doctors Unit of the BMA