AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. September 2003, Volume 5, Number 9.

Policy Forum

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Before Burnout: How Physicians Can Defuse Stress

Stress management techniques can help physicians deal with various personal and workplace stressors in order to prevent and alleviate physician burnout and depression.

Mamta Gautam, MD

Medicine can be a stressful career. In fact, the area of physician health is developing an increasingly high profile, and has become a recognized topic of importance, interest, and research at an international level. Many recent studies have shown that increasing numbers of physicians and residents are feeling stress and burnout and are feeling dissatisfied with their professional life [1-6]. The 2003 Canadian Medical Association Physician Resource Questionnaire found 45.7 percent of responding Canadian physicians reported symptoms in keeping with advanced stages of burnout [7].

The factors that lead to stress among physicians are many and varied. They can be largely divided into 2 categories: personal factors unique to the physician, and workplace factors.

Personality and Stress

Physicians have common personality traits that predispose them to feeling stressed [8-10]. We are very conscientious and spend a lot of time and energy attending to details and to the needs of others. There is an exaggerated sense of responsibility and a need to fix things even when they are beyond our control and a feeling of guilt if we do not meet these perceived responsibilities. We have unrelenting "perfectionistic" traits, constantly striving to do more and be better. This makes it difficult for us to delegate. Physicians have difficulty relaxing and taking care of themselves. Physicians like to be in control and to have control of things and people around them. Much energy is spent in attempts to please everyone, but we are often left with the feeling that we have pleased no one. If we do receive positive feedback, approval, or love, we are not comfortable with this and dismiss or minimize it. There can be chronic self-doubts and insecurity, with a sense of being an imposter and having fooled just enough people so far. Thus, we fear having our cover blown; losing our power and authority, and being "found out." Additionally, we are masters of self-denial and delayed gratification. We put off meeting our own needs until everything else is done, or everyone else's needs have been met. Often, our own needs go unmet.

These personality characteristics are part of the reason we succeed. However, they also make us more vulnerable to stress. Being perfect, conscientious, responsible, and in control requires time and energy. Feeling inadequate and delaying our own gratification prevents us from doing the very things we need to do to better manage our stress.

Stress in the Workplace

Factors in the workplace add to our stress. The workplace is full of pressure to do more with less, as physicians struggle to maintain a high standard of patient care in a changing health care system with fewer financial and personnel resources. We are on call and do not get enough sleep. The patients are demanding. Concerns about litigation and complaints can be real. We are constantly exposed to illnesses and diseases and the risk of violence. We are not fully trained to run the business side of our practice. We do not always feel we have control over how we have to practice medicine. We have little time to remain current in our knowledge, read journals, and attend conferences. We lack time for our families or loved ones. Even less time remains for ourselves.

Not only are physicians feeling stressed, they are working with colleagues and health care personnel who are also feeling the same and cannot provide support.

Burnout and Its Warning Signs

Chronic overstress is described as burnout [11]. Initially, we feel emotionally exhausted. We manage to get through the day at work, but have little else to give. Afterwards, we are exhausted, irritable, and impatient. It becomes so difficult to be with others that we withdraw, depersonalize, and prefer to isolate ourselves. We begin to feel negative about people and work we used to enjoy. We develop a reduced sense of accomplishment and satisfaction from our work and can become cynical and distant. Physicians at this stage often consider leaving the profession of medicine.

Burnout can lead to serious consequences. Medical students and residents experience school difficulty and exam failure. Practicing physicians who are burnt out may be subject to complaints, loss of privileges, or litigation. Emotional illnesses can result such as anxiety disorders, eating disorders, addictions, depression, and suicide [10].

Focus on What You Control

The main approach to dealing with stress is to remember the cause of stress. Regardless of the source, stress comes down to one thing–-that in a given situation, we feel stressed because we do not feel we have any choice or control. Yet, this is only our perception. In reality, we have more control than we think. We focus on controlling and changing things around us, and from that perspective, appropriately, feel we have no control. The only factor we control is us–-our thoughts, feelings, expectations, behaviors, strengths, and weaknesses. We must learn to identify what part of the situation is under our control and focus on that.

Rx for Stress

There are some specific strategies that can keep stress positive and prevent burnout.

First and foremost, take care of yourself well. Make time for yourself. Eat regular healthy meals daily. Develop good sleep habits. Exercise regularly and stay fit. Get a family doctor and consult him or her yearly or as needed. Learn relaxation techniques. Explore meditation and spirituality.

Learn to manage your time efficiently at work. Be organized, schedule realistically, and try not to overcommit yourself. Recognize and accept that you cannot do everything, and set priorities that include yourself, and your family and friends. Set and maintain limits. Learn to say "No." Stop trying to please everyone.

Take regular breaks and vacations. Do not wait for a crisis to force this. Learn to "waste" time—that is, do something you want to do, not something you have to do.

Anticipate and prepare for situations, both at home and at work. Don't spend time trying to do things "the way it has always been done," or the "perfect" way. Look for options. Accept that good enough is good enough. Set realistic expectations of yourself.

Make it a rule not to take your work home. If you have to do this, it should be the rare exception to the rule. At home, define when and where you will work, and stick to these parameters. Give your family your full attention when you are with them.

Laugh more often. Look for and enjoy humor on a regular basis. Share a laugh with family, friends, and colleagues. Add fun to work.

Seek and use supports. Make your family a priority. Have at least 1 good friend. Share concerns with trusted colleagues. Reach out and get a mentor. Ask for help if needed. Foster a team spirit at work.

Take time for yourself and your family without feeling guilt. Acknowledge your guilt, and let it go. See this time as an investment that allows you to be better available for all your other responsibilities. Guilt is the main reason why physicians do not make changes to manage their stress. Let go of your guilt.

Create a financial plan. Stick to basic principles, and reduce nondeductible debts, and plan to save. Do not live beyond your means. Being financially overcommitted is the second most common reason that physicians do not make changes to decrease their level of stress.

While the stress of medicine will always be present, we can work to keep it positive, motivating, and enriching.



References

  1. Spickard A, Gabbe S, Christensen J. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447-1450.
  2. Murray A, Montgomery JE, Chang H et al. Doctor discontent: a comparison of physician satisfaction in different delivery system settings, 1986 and 1997. J Gen Intern Med. 2001;16:451-459.
  3. Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction. J Gen Intern Med. 2002;15:441-450.
  4. Gundersen L. Physician burnout. Ann Intern Med. 2001;135:145-148.
  5. Shanafelt TD, Bradley KA, Wipf JE, Back AC. Burnout and self-reported patient care in internal medicine residency programs. Ann Intern Med. 2002;136: 358-367.
  6. Williams ES, Konrad TR, Scheckler DP. Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manag Rev. 2001;26:7-19.
  7. Canadian Medical Association. Physician Resource Questionnaire. August 2003; unpublished.
  8. Gabbard G, Menninger R. The psychology of the physician. In: Gabbard G , Menninger R. Medical Marriage. Washington, DC: APA Press; 1988: 11-22.
  9. Notman M. Physician temperament, psychology, and stress. In: Goldman LS, Myers M, Dickstein L. The Handbook of Physician Health. Chicago: AMA Press; 2000: 39-51.
  10. Gautam M. Depression and anxiety. In: Goldman LS, Myers M, Dickstein L. The Handbook of Physician Health. Chicago: AMA Press; 2000; 80-94.
  11. Maslach C, Leither MP. The Truth About Burnout. San Francisco: Jossey-Bass Publishers; 1997: 13-15.

Mamta Gautam, MD, is a psychiatrist in private practice in Ottawa and an assistant professor in the Department of Psychiatry at the University of Ottawa. She is an international specialist in physician health with physicians making up her entire patient population. She is the founding director of the University of Ottawa faculty Wellness Program. She is the chair of the Expert Advisory Group to the newly launched CMA Centre for Physician Health and Well-being.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.