Doctor Anna Sherman is a physician practicing in a large hospital in Seattle. She is a wife and a mother of two teenage children. Her lifetime dream: to serve humanity. Her occupation: an obstetrician. Her state of health: stage three burnout. The cause of burnout: excessive and prolonged stress.
Anna’s day begins at dawn. Her mornings consist of patient rounds, individual care and scheduled surgeries. Her afternoons begin with follow-up patient care and include impending births, consultations, emergencies and professional meetings. She faces language barriers, conflicts within her profession and within the hospital, while practicing under the constant threat of malpractice litigation. She returns home at 8:00 pm to have dinner with her family and participate in the busy lives of her husband and teenage sons. At 11:00 pm the house is finally quiet. This is the first private moment Anna has had all day. At 11:10 pm the telephone rings, calling her back to the hospital for a delivery.
Though there are many definitions of “stress”, it can be said that stress is a nonspecific response of the body to any demand made upon it. This demand can be a threat, a challenge or any kind of change which requires the body to adapt. Usually, there is a belief the individual lacks the resources to cope effectively with the demand. The response is automatic and immediate. The stress reaction results from the release of adrenaline into the blood stream. This substance, along with other stress hormones produces a number of changes in the body including an increase in heart rate and blood pressure, faster breathing, tensing of muscles, increased mental alertness and sensitivity of sense organs, increased blood flow to the brain, heart and muscles and less blood to the skin, digestive tract, kidneys and liver. In addition, there is an increase in blood sugar, fats and cholesterol and a rise in platelets and blood clotting factors. While this response is helpful in many short term instances, long term exposure to this generalized stress reaction is harmful and sometimes deadly.
Stress manifests itself in various ways yet generally falls into four general categories:
- Physical: fatigue, headache, insomnia, muscle aches/stiffness, heart palpitations, chest pains, abdominal cramps, nausea, trembling, cold extremities and frequent colds
- Mental: decrease in concentration and memory, indecisiveness, mind racing or going blank, confusion, loss of sense of humor
- Emotional: anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, impatience, short temper
- Behavioral: pacing, fidgeting, nervous habits, increased eating, smoking, drinking, crying, yelling, swearing, blaming or throwing things
There are two kinds of stressors: external and internal. External stressors include:
- Physical environment issues
- Social interaction with people
- Organizational rules and regulations
- Major life events
- Daily hassles
Internal stressors include:
- Lifestyle choices
- Negative self talk
- Mind traps and rigid thinking
- Stressful personality types
Burnout is a state of mental and/or physical exhaustion caused by excessive and prolonged stress. There are three stages of burnout: the stress arousal stage, the energy conservation stage, and the exhaustion stage.
Stress Arousal includes physiological and psychological responses. Irritability, persistent anxiety, periods of high blood pressure, teeth grinding, insomnia and forgetfulness are indicators. Additionally, heart palpitations or arrhythmias may manifest as well as concentration problems, headaches or gastrointestinal discomforts. With the presence of any two of these symptoms, an individual may be experiencing stage one stress arousal.
Energy Conservation is an attempt to compensate for a stress reaction. If such strategies fail, consequences may include excessive lateness, procrastination, excessive time off, decreased desire for sex, persistent fatigue, social withdrawal, feelings of resentment and/or increased substance use such as nicotine, caffeine, alcohol or prescription drugs. Again, any two of these symptoms may signal stage two of the burnout cycle.
Exhaustion is the stage where most people get a sense that something may be wrong. The symptoms include: chronic sadness or depression, chronic gastrointestinal problems, chronic mental fatigue, chronic physical fatigue, chronic headaches or migraines, the desire to get away from family, friends and even recurrent suicidal ideation. As in the previous stages, any two of these symptoms can indicate stage three burnout.
The process of burnout encompasses changes in attitude and behavior impacting the quality of medical services that a physician provides. Ironically, many traits identified as being characteristics of good doctors can also play a major role in the stress that leads to emotional exhaustion which leads to burnout.
Stress and impairment can begin in medical school and residency, where technical aspects of care are emphasized while emotional needs are ignored. Peer rivalry begins and delayed gratification, competition and personal sacrifice are common. Sleep needs are neglected and personal free time is scarce. Hard work, long hours, dedication to quality patient care and a constant striving to remain informed of current medical knowledge shape daily life.
The tendency to work excessive hours along with an overdeveloped sense of responsibility often become permanent features of a doctor’s character. Rather than pausing to reflect, doctors usually respond by working harder, taxing both themselves and their families. Because of personality characteristics, emotional conflict and the changing scope of today’s health care system, physicians are at serious risk for burnout.
Most physicians anticipate stressors when entering the medical profession. Some of these stressors include:
- Pressures of time
- Inherent uncertainty involved in patient care
- Chronic fatigue
- Dealing with life and death or highly challenging issues
- Difficult, demanding or chronically ill patients
- Maintaining clinical competence
However, there are many unanticipated stressors unique to the medical profession which are not anticipated by most physicians. These include:
- Government regulation
- Third party intrusions
- Increase in malpractice litigation
- Pressure to practice defensive medicine
- Diminished public image of physicians
- Breakdown of doctor-patient relationship
- Inadequate support personnel
- Fear of violent patients
- Decreased compensation
- Managed business aspects of practice
These unanticipated stressors have taken and will continue to take a toll on physicians. There is an excessively high patient-to-caregiver ratio. Busy schedules and constant patient contact do not allow for short breaks for emotional recharge. Often there are no systems for caregivers to “cover” for each other. In addition, physicians are increasingly being forced to adopt a businessman’s mentality which conflicts with their desire to provide the best possible professional care for their patients.
What do physicians consider most stressful? According to Dr. Robert Billings, an emergency medicine specialist in Washington State: “There are eight concerns I believe most physicians find stressful in today’s medical world:
- Government regulations
- Demands from insurance companies/managed care
- Increased paperwork
- Malpractice/defensive medicine
- Loss of control over practice
- Decreased income
- Lack of time with family and friends
- Increased cost of malpractice insurance
The landscape of medical care is changing drastically and everyone is being deeply impacted.”
In Issue Brief No.68, September 2003, an article entitled Medical Malpractice Liability Crisis Meets Markets: Stress in Unexpected Places, Robert A. Berenson, Sylvia Kuo, and Jessica H. May reported that in at least 6 of the 12 medical sites studied, many obstetrician-gynecologists had stopped delivering babies to lower their malpractice premiums. Some ob-gyn practices have concentrated deliveries among relatively few physicians in their groups to reduce overall liability insurance premium costs. There were also examples in Seattle of hospitals dropping maternity services altogether or limiting high risk deliveries.
The U.S. Congressional Budget Office recently reported that malpractice costs have risen 22% per calendar year for obstetricians/gynecologists.
As Dr. Anna Sherman states “My practice is in financial peril due to the untenable cost of maintaining my malpractice insurance. I worry about who is going to deliver babies if our legal system is allowed to drive specialists out of practice.”
The answers to physician burnout are not simple nor is there an overnight solution. The key is not to avoid stress but to manage oneself in response to perceived stress in such a way that the negative consequences are avoided as often as possible.
While environmental stressors exist, the majority of stress experienced by individuals is internal and, therefore, under a person’s control. The following guidelines are suggested behavioral changes that may be helpful in managing stress:
Change Lifestyle Habits
- Decrease caffeine in all forms
- Eat a well-balanced diet
- Establish regular exercise
- Obtain adequate sleep
- Create leisure time-even in small amounts at first
Enroll in a Mindfulness Based Stress Reduction Program
- Learn meditation, relaxation and breathing skills
- Establish a personal meditation practice
- Experience the benefits of a living mindfully
Change Stressful Situations
- Manage time issues and resources wisely
- Practice assertive communication
- Adopt an attitude of problem solving
- Assess employment/management resources
- Assess current relationships
Change Thinking
- Look at life with a “yes”
- See obstacles as opportunities
- Reframe unhealthy thoughts
- Maintain a sense of humor
The toll of unmanaged stress is high. The American Medical Association estimates 75% of all diseases being stress related. If stress is not attended to, one or more of the following problematic areas are the consequence:
- Addictive behavior
- Relationship distress
- Emotional/Behavioral consequences
- Professional consequences
- Illness or possibly death
In order to provide quality care to patients, stress reduction is an imperative for physicians. The most effective and healthy way for physicians to teach stress reduction is to learn the methods themselves and be a healthy model for their patients. Many hospitals now offer Mindfulness Based Stress Reduction Programs. Mindfulness training has been found to improve mood and well-being in non clinical populations and is an excellent resource for learning stress reduction practices and skills.
Through the practices of mindfulness, it is possible to learn ways to develop greater calmness, clarity and insight in facing and embracing all of life’s experiences and turning stressful events into occasions for learning, growth and deepening individual strength and wisdom.
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