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April 1, 2013 Volume 77, Number 4
Striving For Wellness: Managing Stress and Recognizing Burnout Jessica A. Alexander, M.D.


“The secret of health for both mind and body is not to mourn for the past, worry about the future, or anticipate troubles, but to live in the present moment wisely and earnestly.”
– Buddha

Statistics
As you read this, try to visualize the last time that you recall truly feeling a deep sense of peace, contentment and/or an awareness of well-being. If you are unable to leap to this visual or feeling, you are not alone among your physician colleagues. Doctors tend to die at a younger age than the general population, and we experience a higher than average rate of suicide, suicidal ideation, substance abuse, dysfunctional work and behavioral patterns (e.g., overwork or “workaholism”) and burnout. Further, approximately one-third of us do not have a personal physician, a number that is twice that of the U.S. population. Lastly, we are deeply remiss in seeking routine or preventive medical and dental care, eating a balanced, healthy diet and exercising regularly. Reports also reflect that at least 20 percent of medical students report underlying depression, a statistic considered grossly under-reported.

Sadly, even as mental health and wellness become part of the corporate vernacular, physicians are discouraged and at times penalized for seeking help, particularly with mental health issues because of vague reporting mandates on many state medical license renewal questionnaires.

Unfortunately, those who do seek help frequently feel obligated to pay cash for their care, fearful of a paper trail.

However, they are undoubtedly healthier and face a much lower risk for burnout, a potential life or death condition. Those who are at risk and fail to recognize the need to ask for help or who are scared to do so may never find their way back to physical, mental or emotional well-being.

What is the Definition of Well-being?
In 2005, the World Health Organization defined well-being as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person’s physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment.” While this description may seem a bit wordy, a simpler view may be: “how we feel mentally, physically, and psychologically each moment of every day relative to our job, relationships and home environment.”

How Do I Know if I Am Not in a State of Well-being?
The easiest way to answer this question, beyond the obvious lack or loss of a job in your life, is to ask yourself if you are experiencing difficulties with managing stress or if you are heading toward or are in burnout. Hans Hugo Selye described our adaptive steady-state capability in his General Adaptive Syndrome. Stress, he theorized, represents the insidiously destructive result of cumulative internal resource depletion. It is essential to understand that each of us has his or her own internal gauge or measure for when we exceed our ability to handle difficult situations; likewise, it is very important not to compare yourself to anyone else on this score.

Anesthesiologists frequently tend to be attracted to the specialty because we enjoy the short but intense relationships with patients, the ability to work with our hands and the increasingly technical inter-specialty equipment we use. We also appreciate the ability to see the immediacy of perioperative pharmacologic and interventional manipulation.

However, the price paid for these seeming advantages is a frequent loss of control, the outward manifestation of which is stress. Anesthesiologists face internal resource depletion daily. We may have no control over the length of a surgery or our schedules, time spent with friends and family, or even knowing when we may eat or use the restroom!

Like all physicians, we are involved in a non-reciprocal relationship with our patients, one that inherently sets us up to be in emotional debt as the caregiver. This situation may be intensified for anesthesiologists who may have less interaction with patients or for those who work frequently with suffering patients such as in an oncology setting. The bottom line: if we do not receive many positive strokes with good outcomes in our doctor-patient relationships, we may lose our ability to empathize. This is one of the key components of burnout.

Other factors that may add to our stress levels with ultimate burnout: 1) the constant need to suppress symptoms of fatigue and exhaustion, 2) economic factors that compel us to perform in the dual roles of doctor and business manager/CEO and 3) difficult relationships with colleagues.

How Do I Know if I Am Burned Out or Heading There?
Burnout is described by Chassot as the triad of emotional exhaustion, loss of empathy and a lack of personal accomplishment. 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 ability to concentrate, avoidance of interaction with others, increased boredom with work, decreased work accomplishment despite seeming hard work, dreading going to work, avoidance of 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. Stress and ultimate burnout may occur even if you are experiencing just one of the above indicators.

Where Do I Go From Here?
If you realize you are at rock bottom or heading there, it is essential to reestablish some modicum of control in your life; this means making some immediate changes. Constant worsening stress frequently exists on a continuum with burnout as a final, potentially life-threatening situation.

Unfortunately, it is likely that if you are at this point, the last thing you want to do is more work. But change requires work. It is imperative to avoid the vicious cycle of avoiding change; this may breed a fear of change that leads to increased stress. Your most pressing task: take a personal inventory immediately. The most practical way to fulfill this directive is to make a list of the top 10 most draining or stressful elements in your life that you perceive need to change. With your checklist in hand, you have three options for each item on your roster: 1) Take care of the issue by yourself and do it; 2) Delegate the task to someone else or hire someone to do it; or 3) Throw it out and let it go! This simple inventory process will take some time and effort, but may be the most valuable gift you can give yourself. It may literally save your life, your career and/or your significant relationships.

The wisdom of John F. Kennedy sums it up best: “There are risks and costs to a program of action, but they are far less than the long-range risks and costs of comfortable inaction.”

A Few Pearls
1.  Do not compare yourself to anyone else. What may be stressful to you many not be to anyone else or vice versa.
2.  Do not wait for someone or something to change and make you happy. Abraham Lincoln perhaps said it best: “Most folks are about as happy as they make up their minds to be.”
3.  As you leave work each day, find a specific and meaningful place between work and home where you literally unload and leave your day’s stresses. It is of great importance to never carry your daily anxieties over the threshold of your home.
4.  Recognize that stressors outside of work may magnify everything that is going poorly in your life. These are just as important to address as what is happening at work. We frequently tend to focus on work stressors because we spend most of our waking hours in this mental and physical space.
5. Live each day consciously and in the moment; make decisions that create less stress for you mentally, physically and emotionally.

Remember, avoidance of important decisions may be just as stressful as those over which you struggle and ultimately do make.



Jessica A. Alexander, M.D. is Clinical Professor of Anesthesiology, the University of Texas Health Science Center at Houston.


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