Doctors and Stress

1 JUNE 2008 IntroductionIt is well-known that being a doctor is studies have shown a higher level of stressamongst Doctors when compared to the generalpopulation. Firth-Cozens1noted that the proportion ofdoctors showing above threshold levels of Stress isaround 28%, in cross-sectional and longitudinalstudies, compared to around 18% in the generalworking population. There is also evidence to show anincreased rate of psychological morbidity, for example,depression, anxiety and substance abuse amongstdoctors.

2 Local data are still limited, but there ispreliminary evidence to suggest elevated anxiety,depression and Stress in Hong Kong medical students2and interns (unpublished data). Rates of Stress areelevated in all Doctors , regardless of the setting inwhich they work, but junior Doctors and femaledoctors are particularly at risk. As Doctors , we areaccustomed to identifying Stress in our patients. Weinform them about health consequences of excessstress and advise them on lifestyle changes andrelaxation.

3 The pathology is usually in others, inpatients we look after. Are we then able to identifystress in ourselves, manage our Stress in an adaptivemanner and seek help when such Stress becomes toomuch to handle?Transactional Model of StressBefore we go further, it is important to understandwhat Stress is. The transactional model of Stress byLazarus & Folkman3conceptualises Stress as resultingfrom an imbalance between demands and resources,or as occurring when pressure exceeds one's perceivedability to cope.

4 Therefore, what appears stressful toone person may be a welcome challenge or all-in-a-day's-work for someone else. More importantly, thetransactional model introduces room for can be reduced by enhancing the individual'sresources, for example by helping people change theirperception of stressors and by enabling them to copeand improve their confidence in their ability to do addition, the demand can also be modified, forexample by increasing its predictability andcontrollability through contingency planning, trainingand risk management.

5 Primary and secondaryprevention strategies are valuable interventions thatmodify the Stress itself and response to Stress . Thesewill be discussed in detail later in the of StressThe sources of Stress in medical practitioners vary withthe type of medical practice (private vs. public, hospital-based vs. community-based) and specialty. There aremany potential sources of Stress that relate to the job, theorganisation, the doctor himself/herself, work-lifebalance and relationships with other people (see Box 1).

6 Usually, a number of these factors are present in anindividual doctor, and therefore the difficulties faced bythe doctor are compounded and addition, there is an apparent mismatch between whatdoctors are trained for and what they are required to example, in the medical curriculum, there is muchfocus on patho-physiology, diagnosis and is now increasing emphasis on communicationskills, law and ethics in medical education. However,other key aspects of a doctor's job like administrative andfinancial management are poorly addressed, and theseoften cause Stress amongst of Stress in DoctorsPhysical complications of increased Stress are well-known.

7 These include: insomnia, gastrointestinaldisturbance, tension headaches, hypertension, fatigue,lowered immunity, menstrual irregularities and sexualDoctors and StressDr. Josephine GWS WongDr. Josephine GWS WongMBBS, MA, MRCP sych, FHKCP sych, FHKAM (Psychiatry)Specialist in PsychiatryBox 1 Sources of Stress for medical practitionersThe jobWorkloadTime pressureAdministrative dutiesSleep deprivationNo regular mealsThreat of malpractice suitsThe organisationCareer structureCareer uncertaintiesInadequacy of resources and staffLack of senior supportCulture and climate of the organisationThe doctorPersonality ( perfectionistic, Type A)

8 High demands on self and othersDealing with death and dyingConfrontation with emotional and physical sufferingRelationships with other peopleStaff conflictsBullyingProfessional isolationPatient's expectations and demandsLevel of support from friends and familyWork-life balanceStress over-spill from work to home and vice versaLack of exercise and other leisure activitiesLack of free timeHome demandsDisruptions to social MAY JUNE 2008dysfunction. Adverse effects of Stress may affect notonly the individual doctor, but also his/her family life,marriage and social life.

9 Furthermore, Stress isassociated with burnout4,5(Box 2) in which 'whatstarted out as important, meaningful and challengingwork becomes unpleasant, unfulfilling andmeaningless. Energy turns into exhaustion,involvement turns into cynicism and efficacy turns intoineffectiveness'. Burnout has been shown to beassociated with increased depression and physicalillness, notably musculoskeletal disorders in womenand cardiovascular disorders in men. Burnout is alsoassociated with an increase in malpractice suits to theextent that American insurance carriers are sponsoringstress reduction seminars as a liability preventionstrategy6.

10 Emotional exhaustion and detachment canfundamentally change a doctor's perception of thedoctor-patient relationship, and can also affectinteractions with family members. Stress also leads toincreased rates of minor and major psychiatric illness,including mood disorders, anxiety disorders, substanceabuse. As a result of Stress , quality of patient care maybe compromised and medical errors may to CareDespite the high prevalence of Stress in Doctors , and amyriad of physical and mental health consequences, Doctors are notoriously reluctant to seek help forthemselves8.