By Alan H. Rosenstein, MD, MBA

Life in the fast lane affects behavior and performance

Most physicians entered the medical field believing that hard work and dedication would provide them with the necessary knowledge and skills to provide best-practice care for their patients. Physicians had unique skill sets and were happy to make the necessary sacrifices in the name of patient care.

All seemed to be going well until the mid 1980s. Growing concerns about variations in diagnosis, treatment, and clinical outcomes of care raised issues about the appropriateness, efficiency, and effectiveness of different practice patterns and about their impact on cost and quality of care. With the growing emphasis on medicine as a business, providers are now being held accountable to external organizations that are telling them what they can and cannot do and paying them less for doing it.

In addition to the issues of increased accountability and decreased autonomy, authority, and control, the overall increased complexity and pressures of the healthcare environment are affecting physicians’ ability to manage the art and practice of providing patient care. All of these factors contribute to increasing levels of anger, frustration, stress, and burnout.

In some physicians, these factors have progressed into bouts of depression, substance abuse, and/or suicidal ideation. Besides the toll they take on personal life and personal satisfaction, increasing levels of stress, burnout, and fatigue are known to adversely affect performance efficiency and promote behaviors that have a negative impact on staff relationships and patient care.

What’s the best way to address the problem? Table 1 gives an overview of steps to consider for helping physicians deal with stress.

Recognizing the problem
The first step is for the physician to recognize that a problem exists. Physicians work under stress most of the time; it goes with the territory. Physicians are so heavily involved in their work and preoccupied with patient care that the thought of being under stress rarely registers. In effect, their focus on work and patient care reduces their sensitivity to and awareness of the impact on others that their actions and behaviors have.

Table 2 shows some of the physical and psychological symptoms of stress. Physicians may recognize in themselves the more obvious physical symptoms of stress such as chest pain, palpitations, headaches, muscle pains, panic/anxiety attacks, and gastrointestinal distress. Frequently, however, they do not recognize the more subtle symptoms such as irritability, mood swings, apathy, loss of focus, sleep disturbance, isolation, and an overall sense of not being happy as stress signals. Getting physicians to acknowledge and accept the fact that they are stressed and that the stress is affecting their moods and behaviors opens the door for next steps.

Once physicians recognize that they are under stress, their customary default position is that they can handle it themselves. They have lived with stress all their lives and feel like they’re managing it just fine. Physicians are reluctant to share their inner emotional concerns. They take pride in what they do; admitting that they are under stress is often self-perceived as a blow to their egos. Discussing the situation with others also opens up concerns about how their competency and ability to perform may be perceived.

Table 3 provides a list of internal and external barriers that may influence physician behavior. Other barriers to consider are the “Who-are-you-to-tell-me-what-to-do?” attitude, posturing around resistance, and a reluctance to change.

Overcoming the obstacles to change
Although physician denial and reluctance are potential obstacles, there are effective ways to overcome these barriers.

First, as physicians, we need to remind ourselves that we are not invincible, that reacting to stress is not a character defect, and that we can take steps on our own to help adjust to the pressures of the surrounding environment. For example, common sense strategies for managing stress include getting enough sleep, eating a proper diet, exercising, and building in some down time for relaxation and even meditation.

Because time pressures and demands often consume the day, physicians must build in personal time as a priority. The following ideas may be helpful:

• Use self-restraint and try not to overextend yourself.
• Sit down for breakfast.
• Take time for a healthy snack.
• Schedule “down time.”
• Read a nonmedical journal.
• Go for a 10-minute walk.

These activities recognize the value and importance of establishing a work-life balance. Making time for family and friends and looking to them for informal friendly advice are also effective stress reducers.

Taking action
Similarly, physicians who see a colleague who appears to be under stress should take the initiative, talk to him or her, and offer to help. Being willing to listen and share thoughts and perceptions can have a tremendous easing effect for both parties.

Some physicians may need a more structured approach. When offering outside assistance, it is crucial to approach the physician in a nonthreatening, supportive manner, placing the emphasis on what can be done to increase the physician’s level of satisfaction. Early interventions should resemble coaching sessions, be provided by trained peers, and be conducted in confidence. They should be provided in a setting that is both convenient and comfortable for the physician.

When physicians have legitimate complaints about things affecting their practices, the organization involved needs to take responsibility for addressing these concerns and work with the physicians to encourage them to raise and discuss issues in a positive, constructive manner.

In most cases, early intervention will be sufficient. Allowing physicians an opportunity to discuss personal problems and assisting them in weighing the value of alternative strategies and appropriate outlets will help reduce stress and increase their level of satisfaction, productivity, and efficiency in both the home and workplace setting.

Occasionally, more comprehensive stress management programs may be in order. When deep-seated issues exist, training programs focusing on anger management, conflict management, diversity management, or lifestyle management may be appropriate. In some cases, more intensive individualized therapy sessions may be necessary.

As physicians, we are a precious resource. For the sake of ourselves and our colleagues, we need a better understanding of our needs, concerns, and priorities. We can then address stress and burnout in a positive, supportive, confidential, collegial manner and provide guidance and assistance to each other in adjusting to the pressures of today’s healthcare environment.

Early intervention through friends, family, colleagues, or more formal physician wellness programs is preferred. Identifying those at risk and working with them early on in the process will increase the chances of success.

Alan H. Rosenstein, MD, MBA, is a practicing internist in San Francisco and medical director for Physician Wellness Services, Minneapolis. He can be reached at ahrosensteinmd@aol.com