Chapter 33: Preventing burnout – manage stress efficiently
|"If you had to define stress, it would not be far off if you said it was the process of living. The process of living is the process of having stress imposed on you and reacting to it."|
- Stanley J. Sarnoff.
Doctors are used to stress. Wounds get infected, complications occur and patients die. Medicine has always been a stressful profession, and doctors have always had to deal with making life and death decisions , delivering bad news, working long hours, managing with little pay , and coping with heavy work loads and bad working conditions. However, in the past, the doctor’s social status, prestige and income compensated for their stress. Today, the struggle to attract patients; the rampant prevalence of unethical malpractises in our profession; shrinking incomes ; declining social status ; and the threat of malpractise suits and legal action have brought many physicians to the brink of burnout. In the US, physician suicide rates are three times that of the general population; "burnout " is becoming increasingly common; and ten percent of physicians will develop a drug addiction during their lifetimes. The figures in India may be even worse, but since we continue to take an ostrich in the sand attitude, we are blissfully unaware of what the facts are.
Some of the most obvious stressors are the demands associated with practicing medicine today. Everyone wants to practise in the cities, where the prestige and glamour is, with the result that competition for patients is intense, and most doctors in private practise have to struggle to survive. The unbiquitous cell phone ensures that doctors are "on call " all the time – they have no time for themselves ! With the introduction of managed care, patient empowerment and the inclusion of doctors under the consumer protection act, this situation is likely to become even worse. Doctors are finding that they have to answer to many masters – hospital trustees, patients, courts, third party payors – and it’s hard to keep so many people happy ! Also, doctors, like everyone else in today’s society which is powered by advertising and marketing pressures to consume more, want to earn more , buy more, and spend more – and keeping up with the Patels and Shahs is hard work !
Fulfilling family and personal responsibilities can create another set of stressors . Doctor’s children often resent the amount of time the parent has to spend away from them – and missing school plays or turning up late for family functions is the norm for most doctors. Spouses try to be understanding, but it can be hard for them to deal with an "absentee husband” or midnight calls and unscheduled emergencies.
Professional boredom can be an additional source of stress. After a few years of practice, when they start getting very busy, many doctors find themselves getting fed up of seeing patients with the same problems day in and day out. They find they are in a rut, and long for new challenges. Ironically, they find that as they become more established in practice, they have a long line of patients who are waiting to see them – and they cannot cope with this demand, because they only have 24 hours in a day. They try to work harder and harder to try to keep up, but often find that they can never catch up.
Finally, an extremely important source of stress is internal. Most doctors have personality traits which make them much more prone to burnout. They are often perfectionists, who because of their self-image and training, need to do everything themselves, and find it difficult to ask for help or support. Also, in order to live up to the superhuman image which patients demand of them, they often act as if they are infallible – an impossible task which soon takes its toll.
Unfortunately, doctors are better at taking care of their patients than of themselves, and while doctors are quick to advise their busy executive patients to "take life easy”, they have not been good at dealing with the stress in their own lives. While stress is a fact of life, remember that there are two types of stress: eustress and distress. Eustress, or positive stress, occurs when you control your stress. Distress, or negative stress, occurs when your stress controls you.
Doctors who find themselves experiencing continuous job-related stress could be headed for "burnout," the popular term used to characterize loss of physical, emotional and mental energy. If ignored or denied, the consequences can be serious - not only for the doctor, but also for his family, patients and colleagues. The symptoms of burnout are as varied as the sufferers. Some doctors become angry, blowing up at anyone who crosses their path - including nurses, patients family members and other physicians. Some become quiet, introverted and isolated, which can indicate the start of a serious depression. Others manifest burnout by under- or overeating , abusing alcohol or other drugs and using mood-altering substances. Some doctors work more because its the only thing they know how to do - they feel that doing more for their patients helps their patients, so they think it will help them, too. Others become chronically late or psychologically absent. Burntout physicians become impaired physicians. Doctors who drink too much, work too hard, take illicit drugs, become depressed, get ill (the list of "impairments" because of burnout goes on and on) and do not do anything about it , are not only harmful to themselves, but also harmful to others. Missing a diagnosis or mismanaging a patient because a physician is too stressed adds to the physicians sense of incompetence and lack of control – and a stressed-out physician is a lawsuit waiting to happen.
Unfortunately, doctors are not very good at recognizing the symptoms of burnout in themselves and the problems are multiplied when they are so impaired that they refuse to acknowledge they have a problem. It is sad but true that while it is easy to recognise problems in other people it is much harder to recognise them in ourselves - and hardest of all to do something about them. While family and friends are often the first to notice the warning signals , most are not sure how to help – after all, doctors are the ones who help others, aren’t they ? How can they need help themselves ? Colleagues , because of professional pride, enter the conspiracy of silence and try to "help” their impaired friend by covering up for him – but end up just making the problem even worse. The burnt out physician can find it difficult to ask for help – and is often trapped and isolated. If you feel your colleague is getting burnt out, make sure he seeks help. Getting help does not mean he is a "bad" doctor it will just make him a better one.
The best defense
Since prevention is better than cure, how can you avoid burnout ? Stress is inevitable , but the good news is that you can learn to manage it. Most of these stress-reduction tips are applied common sense , but you need to have a plan of action in order to implement them.
Learn to take care of yourself. Doctors are good at taking care of everybody but themselves. Doing something good for oneself is a difficult concept for doctors to accept, and many feel that somehow theyre failing as doctors if they want to take time out and be good to themselves. The medical profession is up on a pedestal – and the work ethic is so strong, that many doctors feel they are expected to sacrifice their life ( and their whole familys life ) for their profession . Many perversely take pride in the time they devote to their patients to the exclusion of all else.
So what should you do? For starters, practice what you preach -- eat right, get sufficient rest and exercise routinely. Pay more attention to your bodys signals of stress. Learn to pinpoint the sources of stress and practice stress-reducing strategies, such as yoga, progressive relaxation techniques, breathing exercises and meditation.
Balance your life on a priority basis. One of the best ways to arm yourself against burnout is to have a rich, fulfilling life outside the clinic. Don’t let medicine become both your wife and mistress - look for satisfaction away from work. Achieving balance can be a process that takes considerable time and effort. Just like you cannot get fit by going on a diet and frantically exercising for a month, you have to make life-long decisions about how you will spend your time. You need to learn what to say "No” to – and feel good about your answers. Since it is difficult to strike such a balance alone, many physicians benefit from having a mentor or coach to provide insight and inspiration. A wise and understanding spouse can be a bedrock of support in this endeavour.
Learn to cut back on the routine work. If you find you are getting bored of doing the same procedures day in and day out, re-think your professional goals. After all, taking out the 500th appendix can get to be very monotonous ( unless it belongs to the Chief Minister !) You can choose to reduce your work load, or accept only patients who have complex problems which challenge you. While many doctors are reluctant to turn patients away, because they are scared that a reduced work-load will translate into a reduced income, the fact is that if you refuse to do work you don’t like, you will find yourself attracting the work you do like – and this will actually improve your efficiency – and your bottomline as well !
Develop a strong support system. Doctors have a hard time reaching out for help because they do not like to feel they cannot cope with their own problems. Support from other doctors ( who have "been there, done that” and can empathise with what you are going through) is extremely helpful. Physician peer support groups, where a group of colleagues meet on a regular basis and develop the security to share feelings and concerns (about patients, work, family problems, or anything else) , can greatly reduce a sense of isolation and enhance a sense of wellbeing.
There are many dos and donts, and most are easier said than done. However, you can change your work habits if you resolve to do so.
Doctors who enjoy their work and find meaning in it, have high self-esteem – one of the best buffers against burnout ! When you work, work hard. But also learn to work smart, delegate and manage your time well, so you find time to play as well ! Remember, " All work and no play makes Dr Jack a dull man ” !
Learn to rest. Keep your evenings and weekends free to recharge your batteries. Allow yourself to take time for your own personal self care. After all, how can we help others if we cant help ourselves?
Get regular exercise. Spend money by joining a gym or hiring a personal trainer- this will ensure that you actually do work out. Even if you go twice a week, youll feel mellower and more energetic. Hike, play tennis, or engage in other physical activities that give you pleasure.
Learn to practice voluntary simplicity. The secret of contentment is in wanting what you have, not in having what you want.
Release yourself from unrealistic expectations. Its not true that the harder you work, the better your work. Remember that if you are good to yourself, you will end up being better to your patients !
Develop your hobbies and interests. Painting, collecting, or anything you always wanted to do but never got around to are all good starts.
Dont let petty annoyances sap your energy - "dont sweat the small stuff" .
Dont try to do "everything." Understand your limits and don’t try to perform all procedures. Don’t try to treat medical problems which are beyond your competence – learn to refer or call for a consultant
Don’t run around from clinic to clinic, hospital to hospital and spend half your life commuting – this is a waste of your energy and productivity. It’s far better to find a niche and focus on this, and then allow your patients to come to you rather than go hunting for them !
Life is short and the practice of medicine is getting more stressful. You can only do yourself and your patients a favor if you balance your life and prevent the scars of "battle" from wounding you permanently. However, even burnout can be a gift, and as Hemingway said, "We get stronger in all the broken places.” If we learn to take time to enhance our relationship with ourselves, family and friends, even burnt out physicians can renew themselves, making themselves better doctors – and better human beings.