October 2000
Volume 64 |
Number 10
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WHAT'S NEW IN...
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| ...Stress Management:
Slaying the Dragon |
Jessie
A. Leak, M.D.
| This
is the first of a two-part series on stress management in
anesthesiology. |
What do you want to do? What do you want to be? What do you
want to have? Where do you want to go? Who do you want to go with?
How the hell do you plan to get there? Write it down. Go do it.
Enjoy it. Share it. It doesn't get much simpler or better than
that.
– Lee Iacocca
In
1987 at one of my first professional lectures, I was astounded
to find the meeting room filled to capacity with standing room
only. I could not imagine that my talk on the esoterica of learning
and teaching styles in anesthesiology residencies was that popular.
I subsequently found out that the lecture following mine was on
physician stress and that everyone was flooding in early to get
a seat.
I stayed for that talk. The speaker opened her presentation with
the question, "How many of you are stressed?" Almost
every hand in the room went up. Her next question was, "How
many of you have ever admitted this to a boss or colleague?"
With heads lowered, a few individuals in the room slowly raised
their hands.
To admit to being stressed was, at that time, a sign of weakness.
After all, compared to everyone else, doctors were supposed to
be stronger, smarter, immune to the mundane stresses of life,
basically on top of the world. How could we admit that stress
was an issue?
However, the audience reaction to that lecture was overwhelming.
It was as if a dam had opened. During that session, confessions
of near emotional breakdowns, loss of family life, divorce, business
problems and an inability to get along with colleagues and partners,
just to mention a few, were all openly discussed. For the first
time in my experience at medical meetings, the problem of stress
was openly recognized as a profound and potentially job-threatening
and life-threatening issue.
A 1994 study reported that nearly one-half of the anesthesiologists
surveyed felt that they were under chronic pressure.1
Female physicians between the ages of 45 and 55, without a partner,
with full-time hospital work and the attendant administrative
responsibilities and in an understaffed area are at greatest risk
to experience chronic pressure or stress; this group also commits
suicide at six times the rate of the general population.2
Finally though, in 2000, we are willing as a specialty to recognize
stress as an ubiquitous, potentially harmful entity, as was evidenced
by the focus on stress at the recent 12th World Congress of Anaesthesiologists.
But little is being done in most anesthesiology departments to
provide relief. To minimize stress, it therefore becomes incumbent
upon each of us individually to recognize our own signs of burnout,
accept that we are human and most importantly "make our peace"
in whatever way necessary with our work environment.
Why Is the Specialty of Anesthesiology So Stressful?
Most anesthesiologists will tell you that it is not the tough
cases or the challenging medical problems that cause stress. They
will also tell you in the next breath that they cannot think of
another specialty with the perks of this field: short but intense
relationships with patients, seeing the immediate results of pharmacologic
manipulation, working with your hands, etc.
The price, however, that we pay for these seeming advantages
is loss of control – the outward manifestation of which
is stress. We simply exceed our adaptive steady-state capabilities
described by Hans Hugo Selye in his General Adaptive Syndrome.
Stress, he theorizes, represents the insidiously destructive result
of cumulative internal resource depletion.
Anesthesiologists face resource depletion daily. We have no control
over how long it will take a surgeon to finish a case, we have
no control over our schedules and we seldom can plan anything,
including being with our families. Sometimes we have little control
over when we might eat a meal or even when we might go to the
restroom!
In the bigger picture, doctors, in general, are involved in
a nonreciprocal relationship with patients, one that inherently
sets the physician up for emotional debt as the caregiver. This
situation, some experts believe, is intensified for many anesthesiologists
who, except on a limited basis in the immediate perioperative
period, have little interaction with patients. This phenomenon
may be further exacerbated for anesthesiologists (and other physicians)
who work in areas with many suffering patients, such as an oncology
setting. In other words, if we do not receive many positive strokes
with good outcomes in our doctor-patient relationships, we may
lose the ability to empathize. A sort of chronic depersonalization
sets in that can lead to emotional exhaustion and burnout.
Other factors contributing to stress (loss of control) for anesthesiologists
may include: 1) the constant need to suppress symptoms of fatigue
and exhaustion, 2) economic factors that compel the physician
to perform in the dual role of physician and business manager/CEO;
and 3) difficult relationships with colleagues.
How Do I Know if I Am Burning Out?
Chassot describes the symptomatology of burnout as a triad:
emotional exhaustion, depersonalization (loss of empathy) and
a lack of personal accomplishment.3
Some of the symptoms of burnout may include: feeling tired even
with adequate sleep, work dissatisfaction, forgetfulness, sadness,
irritability, increased incidence of illness, subpar job performance,
substance abuse, decreased concentration, avoidance of interaction
with others, increased boredom with work, decreased work accomplishment
despite seeming hard work, dreading going to work, avoiding social
activities, feeling like work is a dead-end (why bother) and the
perception that what you were hired to do is not meeting with
reality.
It is an unfortunate aspect of the physician's ideology that
it may actually be desirous in some way to experience burnout
in order to prove a certain level of achievement a sort of club
with exclusive membership open only to those who, so-to-speak,
suffer well.
When you feel like you have joined the club, it is time to take
action. Suggestions for moving in the right direction will be
addressed in the second segment of this article, which will follow
in the November issue of the ASA NEWSLETTER.
Bibliography
Chassot P. Stress in European operating room
personnel.
World Congress of Anaesthesiologists, 2000 Proceedings; 2000:63-65.
Gaba DM, Howard SK, Jump B. Production pressure
in the work environment. California anesthesiologists’ attitudes
and experiences. Anesthesiology. 1994; 81:488-500.
Heim E. Stressors in health occupations. Do females
have a greater health risk? Z Psychosom Med Psychoanal.
1992; 38:207-226.
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Jessie
A. Leak, M.D., is Associate Professor, Department of Anesthesiology
and Department of Symptom Control and Palliative Care, M.D.
Anderson Cancer Center, Houston, Texas. |
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