Understanding and dealing with stress: physician's perspective

This essay discusses stress and its consequences in health care professionals and
students. Stressor affecting health care providers seem to be multifactorial. It can
range from serotonin disturbances and psychosocial instability of a person to social
support of the care provider, their self-respect and control over their life. Stress,
especially chronic, is extremely dangerous as it can affect long term physical, mental
and social wellbeing of person.

Proportion of distress for the health care providers range from 5-50%. This range is
wide because different studies could use different meanings of distress. Stress is more
associated with physicians in training than the general population. Depression, which is
caused by excessive stress, affects 1/7 of college students, while for medical students
this number ranges from 29% in western countries to 50% in China. Rotations in
multiple clinics is stressful due to changing learning environment. At the end of the
training, competitive application to the desired residency position is the source of huge
stress. Practicing doctors have stress that is caused by rotating work shifts, emotional
stress and long work hours, excessive work demand in medicine, low income, less
autonomy and less discretionary power cause stress, and consequently anxiety and
depression.
Stress result in low commitment to the job and leaving the job. It can also affect life
dissatisfaction. Early diagnosis of stress is near to impossible. First of all, psychic
problems as stress, anxiety and depression, seen in some patients as excessive
complaint about everything in ones, whilst other stressed patients never complain.
Secondly, doctors usually try to treat themselves, instead of going to psychologist or
occupational physician. This is because, some claim, doctors are not sure if what they
say to psychiatrist will be confidential.

In my opinion, there could be two school of thought on what causes the psychiatric
problems, as stress, anxiety and depression, to the health care providers. On the one
hand, data from Taiwan show that depression and stress level increased during the
internship and subsided two weeks after it. They concluded that not the internship
itself, but the anticipatory worrying and stress causes depression. Although other
authors claim that internship itself causes depression and stress, they agree with their
Taiwanese colleges: stress is due to external stressor and does not depend on
personality. On the other hand, depression, anxiety and stress level can be associated
with age and gender. In addition to that, any other personal traits, such as 5-HTTLPR
region in serotonin transporter, can make person more or less susceptible to anxiety
and depression.
Female health care providers tend to perceive more job stress than their counterparts
do. Perhaps because of this, they usually have increased level of anxiety, depression
and psychological malaise. This is, in my opinion, a confounder, meaning that female
physician can undergo patronization or they can be treated inappropriately, which, in
turn, could cause anxiety and stress. Age seems to be inversely related with stress.
Senior physician feel stressed less often. The reason could be the experience they
have: they anticipate probable results and know what to do. From personality traits,
neuroticism in women and reality weakness in men correlates with job stress and
stress reaction in doctors. This is another prove that people who are morbidly
perceive the surrounding, get more stressed. On the other hand, extroverts tend to feel
less stressful.
As said before, physicians work is stressful. One of the highest stressor turns out to be
postgraduate internship time: it is the highest risk for depression and anxiety. In turn,
perceived stress during last year of medical school leads to stress during internship. In
my opinion, these two years are defining moment for stress to occur, because this time
is most ambiguous moment to plan the future and it is first step into the unknown.
Other factor that aggravates stress and depression is workload, which exist as there
are high demand on quality of doctors and quantity of doctors. However, discretionary
power can make job less stressful. This might be the reason why private practitioners
are less anxious, less depressed and have less psychic disorders. Social support also
seem to ameliorate stress. Indeed, total life satisfaction is significantly increased in
doctor or doctors in training who live with partners. One finding, which is contradictory
for me, suggest that healthcare professionals who are overcommitted and put extrinsic
effort are more prone to stress and depression. It is contradictory, because usually
people get depressed in high effort-less reward conditions. On the one hand, if doctors
works hard with empathy, he will get good rewards in the form of healthy patient, self-
respect and personal thanks from the patient. On the other hand, people working in
ICU and palliative/hospice care condition when almost every other patient dies
people get little reward. Another stressor breaking bad news. It is extremely stressful,
because even before the doctor meets the relatives, he gets anticipatory stress and
fear, which can impair proper communication with the relatives. The latter, in turn, can
cause anxiety and depression.

Although stress is inevitable, stress that health care providers encounter can have
severe consequences. Firstly, stressful environment severely impairs academic
performances, physical health and psychosocial well-being. Work stress is significant
cause of migraine attacks and hypertension. From psychosocial pointview, stress can
cause cynism, anxiety, depression, insomnia, suicide thoughts and other stress-related
disorders. One of the consequences is burn out syndrome (aka BOS). BOS is caused by
inadequate control over work, frustrated hopes and expectation, low satisfaction.
Doctors having BOS usually appears as lacking energy, highly irritable and
demoralized. It is significant to treat it because BOS itself is risk factor for myocardial
infarction and coronary heart diseases. It also causes hypofunction of HPA and, as a
result, decreased capacity to cope with stress. BOS is more associated with caring
professions in medicine: ICU nurses and charge nurses are at high risk rather than
outpatient nurses.

From what was said above it seems that people who are more experienced and who
have social support are less prone to stress. In my opinion, standardized patients are
crucial to prevent stress among physicians. Firstly, it gives a person an experience with
stressful situations and teaches how to cope with stress. Secondly, it gives a person
support he needs before, during and after stressful encounter with standardized
patient as professors and peers help and guide the patient. Social support on health
care provider is difficult to control, because it is personal life. However, various medical
associations help a person to take part in their job, i.e. taking control, and give a
person mental and social support in way of advices, legal services, etc.

To conclude, stress turns out to be major part of health care providers life. It can be
caused by personal unique features of a person, or from persons surroundings:
stressors in in job and related to it and in personal life. It seems that both better
preparation to stressful situation on controlled environment and good relationship with
relatives and coworkers can be helpful in fighting stress.
 References
Ahmed I., Banu H., Al-Fageer R., Al-Suwaidi R. (2009). Cognitive emotions: depression
and anxiety in medical students and staff. J Crit Care. 24(3):e1-7.
Brown R., Dunn S., Byrnes K., Morris R., Heinrich P., Shaw J. (2009). Doctors' stress
responses and poor communication performance in simulated bad-news consultations.
Acad Med. 84(11):1595-602.
Chen C.Y., Lin S.H., Li P., Huang W.L., Lin Y.H. (2015). Medicine (Baltimore). 94(2):e389
Gramstad T.O., Gjestad R., Haver B. (2013). Personality traits predict job stress,
depression and anxiety among junior physicians. BMC Med Educ. 13:150
Kakiashvili T., Leszek J., Rutkowski K. (2013). The medical perspective on burnout. Int J
Occup Med Environ Health. 26(3):401-12
Klaghofer R., Stamm M., Buddeberg C., Bauer G., Hmmig O., Knecht M., Buddeberg-
Fischer B. (2011). Development of life satisfaction in young physicians: results of the
prospective SwissMedCareer Study. Int Arch Occup Environ Health. 84(2):159-66.
Kuo W.Y., Huang C.C., Weng S.F., Lin H.J., Su S.B., Wang J.J., Guo H.R., Hsu C.C. (2015).
Higher migraine risk in healthcare professionals than in general population: a
nationwide population-based cohort study in Taiwan. J Headache Pain. 16:102
Magnavita N. (2015). Work-related symptoms in indoor environments: a puzzling
problem for the occupational physician. Int Arch Occup Environ Health. 88(2):185-96
Magnavita N., Fileni A. (2014). Association of work-related stress with depression and
anxiety in radiologists. Radiol Med. 119(5):359-66.
Mealer M., Burnham E.L., Goode C.J., Rothbaum B., Moss M. (2009). The prevalence and
impact of post traumatic stress disorder and burnout syndrome in nurses. Depress
Anxiety. 26(12):1118-26
Slavin S.J., Chibnall J.T. (2016). Finding the Why, Changing the How: Improving the
Mental Health of Medical Students, Residents, and Physicians. Acad Med. 91(9):1194-6.