Jessica A. Alexander, M.D.

“Differentiation, infinitely contradictory, must remain, but it is not necessary that we should hate each other; it is not necessary therefore that we should fight each other.”

— Swami Viekananda

nger and hostility are endemic among us. Estimates are that at any given time, approximately 20 percent of the population is hostile enough to endanger their health or that of others. Risks to any one individual may include heart disease, back pain, headaches, indigestion, decreased immunity or violence. Another 20 percent experience low levels of hostility and anger that can escalate.¹

A close friend and colleague once told me that many of us go into this specialty for one or both of two reasons: we love the fact that we can control everything in our environment (at work) and/or we crave the adrenaline surge, e.g., those of us who do trauma or transplant anesthesia. Total control over the life of another human being is the ultimate in power. Unfortunately the very things in our personality that draw us to the specialty and make us good at what we do can make us more susceptible to anger and hostility, often at a high level. When there is any failure to control anything in our lives, we may manifest the emotions of anger and the actions of aggression.

Unfortunately control at work (e.g., a successful anesthetic given) does not always serve us as well in one or more of the other and equally important parts of our lives: our personal lives, our physical environment, management of our finances or, most importantly, in our physical/spiritual life. Many of us become unable to differentiate anger from the other range of emotions that we should normally feel: hurt, sad, worried, scared, guilty, joyous, fearful. When we get into “control mode,” the only emotion that occurs when we lose control is anger.

Physically, when anger sets in, we experience clammy palms, tachycardia, bruxism/TMJ problems, flushing of the cheeks, higher blood pressure and/or increased blood flow to the hands. Basically it is the “fight” part of the autonomic nervous system’s “fight or flight” mechanism — the adrenaline surge associated with increased cortisol. To become less angry is extremely important, not only to increase our life expectancy and to decrease our propensity for physical and psychological morbidity and mortality, but also to increase the quality of our lives, both at work and away from work.

Why Do I Come to Anger So Easily?
Anger is an instinctive response to a perceived threat and/or the frustration associated with the inability to meet our goals or desires. It is known that anesthesiologists experience stress in record numbers as opposed to other specialties and the population as a whole. It is important to note that we are one of the few specialties where we may be totally alone and isolated (in an operating room) with our thoughts and perceptions. This can result in fear; fear of loss of control, fear of boredom, a fear of change. The perception that we are in an innately hostile environment leads to a perception of a loss of control, hence anger. This vicious cycle perpetuates the aforementioned leap to anger.

Many of us are taught to suppress our anger; nonetheless, the expression of anger is cultural. In general the major function of anger is maintenance of a certain social order. In the United States, our mores have changed drastically in the last three decades. What was once deemed as unacceptable and not able to be understood is now accepted as legitimate, although not always correct. A great example of a more recent phenomenon is that of “road rage.” In our society, anger is seen as an effective way (particularly for successful men as opposed to “aggressive” for women) to get what we want.

Repression of anger is expected in many cultures; in Japan, for instance, an angry individual is more likely to become excessively polite with a neutral expression. In the Middle East or in Latin cultures, the first response to this emotion is to brood. In many cultures, self-anger is superseded by anger in a community/country, and it is to be suppressed, to a point — these cultures believe that everything that happens is predestined. Cultural mores do not transfer from one place to another. We live, however, in a new melting pot; in our society as a whole, we must expect the unexpected when it comes to anger and aggression.

It is important to note that anger and depression may occur simultaneously. When one is unable to re-establish control over one’s environment, depression may set in. Interestingly many depressives turn their own anger inward (repression) but have no problem expressing anger and hostility to others. In the area of “home/personal life,” the two issues that couples/families fight about the most are housekeeping issues (physical surroundings) and money. To break this cycle, it is important to step out of one’s own self-righteous observations and to realize that the efforts we have traditionally used to regain control (over the other person) are not working. Actually developing a simple plan to communicate about these issues (stepping out of the “anger” box) can be the most effective way to regain momentum in the relationship and diminish anger and depression. Perception of a situation is what ultimately leads to anger; objective facts often get lost in any environment, whether it be at work or outside of work.

So What Do I Do Now That I Have Accepted That I Am Angry?
It is important to recognize the signs: Accept that you have lost control and may have excessive anger and irritability, loss of interest in things that you have enjoyed in the past, changes in appetite and/or sleep, feelings of hopelessness/despair, fear, fear of being stuck in a rut, anxiety and/or panic, crying for no reason, suicidal ideation, sabotaging success at your doorstep, substance abuse, an increase in addictive behaviors and/or a recognition of depression.

We frequently choose to do nothing about our anger until we have hit rock bottom. If you are there or perceive that you are getting there, it is important to re-establish your own personal equilibrium:

1) Awareness of yourself at all times is paramount. Is it anger, or is it that you really feel hurt, sad, worried, scared, guilty, joyous, fearful or many of the other of life’s emotions? It is important that as soon as the awareness of anger surfaces, you quickly catalog your true feelings. This should be done within five or so minutes, otherwise anger and aggression will continue.

2) To delineate your true feelings, you have to really focus on your conscious thoughts, your environment and on your physical sensations (tachycardia, heartburn, etc.).

3) While trite and overused, it is important to stay grounded as you go through these quick observations and processes. Each of us has to develop a way to approach this goal.

4) When you recognize fear as the emotion driving you, you have to realize that you must make a conscious choice to stop and consider your options, e.g., “Am I going to be poor,” “Am I going to lose my house?” You have choices to make (e.g., “I will stop spending so much,” “I will make different financial choices,” etc.) and can move out of fear. It can be one of the most immobilizing of all emotions.

5) Enjoy and celebrate the awareness of who you are fully instead of imagining who you are supposed to be. This will most certainly change the expectations that you may have set for yourself (and you will ultimately doom yourself to fail).

6) Do not try to over-analyze. Breathe deeply from your diaphragm, as opposed to shallow/fast “fight or flight” breathing, and simply allow your intuition to guide you. It is important to eliminate rule-making for yourself and simply be “in-choice” mode.

7) Eliminate that “I can’t” chatter in your head and replace it with “I have a set of choices here; which road will I choose?” (See “Practical Tools for Diffusing Anger” at <www.ASAhq.org/Newsletters/1999/08_99/whatsnew0899.html>.²)

Additionally it is important to: 1) Avoid venting — it simply perpetuates the anger; 2) Nip anger before it becomes bigger than the original mitigating factor; 3) Step-by step, try “slipping into others’ shoes”; 4) Discard the issue causing your anger; 5) “Chill,” either by deep breathing, exercising, etc.; and/or 6) Try being communicative (assertive), not aggressive. This allows you to ask others to simply change a specific behavior rather than the person themselves.

“Learn to be silent.
Let your quiet mind
Listen and absorb.”

— Pythagoras, Greek philosopher, 580-500 B.C.

How Do I Deal With the Disruptive Physician?
Unfortunately, while we may personally be trying to deal with our own anger issues, work and life move on. If you are in a position of leadership, you may have to deal with a disruptive physician colleague. It is important to frame the experience for both individuals as objectively as possible. Several tenants: 1) Provide protection for involved employees, if indicated; 2) Confront the offender with data, authority and compassion (avoid anecdotal data); 3) Listen and empathize; 4) Never confront alone; 5) Offer workplace training as indicated, i.e., sensitivity training, continuing medical education, etc.; 6) Follow up after your initial discussion (with someone else present); 7) Document your discussions and interventions; and, most importantly, 8) Practice what you preach.

Anger is a driving force in the lives of many anesthesiologists, and dealing with it is an important step in stress management. We must be the best physicians and our best selves so that we can serve those who entrust their lives to us.


References:
1. Chichester B, Garfinkel P. Stress and disease and overcoming anger. In: Stress Blasters. Emmaus, PA: Rodale Press, Inc; 1997:20-25.
2. Leak J. Stress management: Calming the lion. ASA Newsl. 1999; 63(8):21-22.

Jessica A. Alexander, M.D., is Clinical Professor of Anesthesiology, University of Texas Health Science Center, San Antonio, Texas.