Doctors and their spouses speak: stress in medical practice

Erica Bates

Doctors and their spouses speak: stress inmedical practice

Abstract Many sociological articles assume that the patient-doctor relation-ship is satisfactory for the doctor and unsatisfactory for the patient.This paper describes a research project on stress among doctors andtheir families. It seems that the stress the doctor feels may significantlycontribute to the problems of the patient-doctor relationship. Forexample, doctors who cannot cope with their own stress may find itdifficult to help their patients cope with stress. The implications ofthese findings are discussed in the context of the social structure ofmedical practice and medical education.

Introduction

Much sociological literature on the relationship between patients anddoctors emphasizes the power of the doctor and the weakness of thepatient, the inadequacy of the information which doctors give patients,and the lack of understanding doctors have of patients' problems.' ~ ^

The sociology of the professions as a whole, epitomized by the medi-cal profession, emphasizes autonomy and control as being the two majorcharacteristics of a profession.^'^''" Doctors are said to be able tohave almost total control over their work, and to evaluate it themselves.They have a great deal of prestige and a high income. Freidson says that,apart from autonomy and control, the medical profession also needs 'apublic belief in the profession's competence, and in the value of itsprofessed knowledge and skill'." But he adds 'after becoming auton-omous, the profession has less and less come to reflect what the publicasks of it and more and more come to assert what the public should getfrom it'.'^ It is this point which has now become important, for itseems likely that, if the public no longer fully supports the profession'svalues and institutions, the people working in that profession willbecome isolated and frustrated because they can no longer achieve theirexpected autonomy.

This research then focuses on the doctor's side of the doctor-patientrelationship, and suggests that it is not only the patient who is uncom-

Sociology OfHealth and Illness Vol. 4 No. 1 1982©R.KJ". 1982 0141-9889/82/0401-0025 $1.50/1

26 Bates

fortable in this relationship. Indeed, if the doctor is under considerablestress, this will inevitably make it harder for him or her to relate em-pa thically to the patient, to treat the patient as a partner in the trans-action, and to understand the problem from the viewpoint of the patient.The sociology of the professions has tended to make some unstated as-sumptions: that doctors are enjoying their work, that the doctor, at least,is comfortable in the relationship, that doctors are relatively confidentin what they are doing to, for, or with the patient, and that the patientas a person is relatively unimportant to the doctor. These assumptionsremain to be demonstrated or disproved, but should be more explicitlydiscussed. The research reported here is part of the process of clarifyingsome of these issues.

In any search through the literature, there can be .found occasionalarticles discussing stress in relation to doctors. To start with the mostserious consequences of such stress, it is said to show itself in the suiciderates of doctors'^''''•'^ which are alleged to occur at a rate two anda half times as great as that of the rest of the population, and oneand a half times the rate for social class I. Alcoholism and drug addictionare also high among doctors.'^''^''*''^''* Even more pervasive is de-pression among doctors,'^"'® and the doctor population in generalis said to have a high level of anxiety."'^" It has been shown thatclinicians are more anxious than non-clinicians and younger doctorsmore anxious than older doctors." '^ ' '" It has been suggested thatthe superior student who is the only one able to enter the medicalfaculty nowadays, tends to be anxious by way of being a goodstudent ;^^'^'' such people are more liable to overwork themselves; partlybecause they are anxious and partly because they gain emotional rewardswhen they receive the praise and respect of their fellow workers such asnurses, and the gratitude of the patients. Maddison, for example, sug-gests that overwork by doctors should be seen as a symptom, not acause, of stress.^°

It is, of course, possible that many of these stress reactions are aresult, not of medical practice, but of the personality types of studentsattracted to medicine. Waring''' and Vaillant'* suggest this, but theirevidence is quite inconclusive, and until some long-term, large-scale follow-up studies of comparison groups are done, the simplestexplanation of doctors' stress symptoms would seem to be sought in thepractice of their profession, which has obvious tendencies to be stressfulbecause it involves the treatment of ill and dying people, the handlingof forbidden parts of the body and the great temptation to overwork.In a survey of nearly 100,000 Americans," satisfaction with one'swork was rated as a more important component of happiness thananything else except love and marriage, but doctors in particular rated

Doctors and their spouses speak: stress in medical practice 27

themselves as relatively unhappy compared to other professionals andother occupations.

Some hypotheses have been suggested when writers have attemptedto analyse the reasons for this stress. Cramond*^ suggests that partic-ularly troublesome areas are the management of chronic, frustratingcases (because of the failure of treatment), diagnostic difficulties, theimpact of medical work on family hfe, and the death of children. Othersuggestions have been made: the medical profession is 'unforgiving oferror'," that doctors lack an understanding of their own emotions,17,23,24 j-j j j ^ jg nearly impossible to combine objective detachmentwith compassionate concern,^'' role strain,'^ the weight of respon-sibilities the doctor carries; ® all these transform doctors into a shellof their former selves,^' and force doctors into a changing role whichitself is stressful.^"

Methodology

My own studies of stress in doctors have now extended over six years inAustralia, and include studies of junior resident medical officers,^'-^^'^' registrars, specialist consultants empolyed by hospitals with right ofprivate practice, and general practitioners,^^ totalling altogether 146doctors. The research reported below is a part of the most recent seriesof projects; it relates to 105 of these doctors: 51 general practitioners,24 specialist consultants and 30 registrars. The distribution of the sampleis shown in Table 1.

Table 1 Distribution of sample

N Mean age

Total number interviewedGeneral practitionersRegistrarsSpecialists

The study was carried out in Sydney, Australia, and consisted of a long,semi-structured interview, tape-recorded, with the doctors and theirspouses, who were interviewed separately in their home or at work.

All research conducted by interviews or self-reporting methods isvulnerable to the suggestion that the results may not be fully accurateand this research is no exception. Yet much information is only obtain-able by these methods, and all the researcher can do is to be aware ofpossible inaccuracies and to explain to the reader just what precautions

105513024

45 years29 years41 years

28 Bates

were taken to make the information as accurate as possible. Several suchmeasures were taken in this research. The interview questions werealmost entirely open-ended, and interviewers were not permitted to leadthe doctors; this was checked by listening to the tapes.

In spite of this precaution, it is possible that some doctors exaggeratedthe stress of doctoring, mainly because, as one subject said, no outsiderhad yet asked him these questions and it was for him an excellentopportunity to talk about his problems rather than the problems of hispatients. In spite of this caveat, however, the emphasis with which thedoctors and their wives expressed their frustrations came across veryforcefully on the tapes, and the three research assistants who assisted inthe analysis of the tapes commented on the strength of the feelingswhich was evident.

Further, doctors are generally reported as wishing to present them-selves as coping people, and in control of their own feelings. Theiradmission that they experience high stress and emotional exhaustiontherefore goes against the normal expectations of their role and so ismore likely to be a genuine expression of their feelings.

Fifty-one doctors were general practitioners. A geographico-socialatlas of Sydney^^ was used to divide Sydney into relevant areas. Thenumber of genera! practitioners in each suburb was estimated by coun-ting the number of doctors listed in the Sydney telephone directory,and checking to see whether tliey were specialists or general prac-titioners. For each suburb, a number of general practitioners were thenchosen in proportion to their total number, by random number alloca-tion. 100 doctors were selected, to allow for refusals and changes inpractice patterns, deaths and illness. In the final survey, we used 86 ofthese 100 names; 10 doctors were no longer practising and 25 refusedto be interviewed saying they were too busy. Since the main stress ofthe general practitioners was of their overwork, this seems likely to be agenuine reason for the refusals.

Fifty-four doctors were registrars or staff specialists in teachinghospitals. We obtained from each teaching hospital a list of their marriedregistrars and qualified specialists, and sorted them into specialities. Wethen selected from each speciality in proportion to its numbers, againby random number allocation. Only two refusals came from thissample. Four of the doctors whose names were on the list turned outby that time to be in private practice, so that instead of interviewingonly 50 hospital doctors, we also interviewed 4 specialists in privatepractice.

The mean age of the registrars was 29 years, the specialists 41 yearsand the general practitioners 45 years. Of the 54 staff registrars andspecialists, 35 were in physician-type fields, including anaesthetics.


administration, gastroenterology, paediatrics, pathology, psychiatry,neurology, nuclear medicine, cardiology, rehabilitaion, renal medicineand general medicine, and 19 were surgeons in various surgical sub-specialities such as: orthopaedics, general surgery, obstetrics andgynaecology, ear nose and throat, renal surgery, cardio-thoracic surgeryand neurosurgery. Our interviews dealt with the personal as well as theprofessional aspects of being a doctor and being married to a doctor;this report deals specifically with satisfactions and stresses related tomedical practice, including some of the overflow into the doctor's familylife. In each case, the spouses were interviewed separately, although ofcourse there were sometimes several days between the interviews andthe couple could have discussed the first interview before the secondtook place. From internal evidence in the tapes, this does not seem tohave happened very often. Three general practitioners, three registrarsand two specialists were female; all but two of these were married toanother doctor; since the overwhelming number of spouses were female,this report will frequently refer to 'wives'.

Results

Satisfactions in medical practiceIn order not to bias the interview towards a series of complaints, theinterviewer first asked what was the main satisfaction the doctorsgained from their work. The answers showed some variation betweenthe general practitioners and specialists, as one might expect. Table 2shows the distribution of replies. It is clear that for all doctors, thegreatest satisfaction in their work comes from helping people, gettingthem better, seeing the results of their work when patients improve inhealth, and having patients appreciate their services and express grati-tude.

However, in the second main source of their satisfaction, the generalpractitioners and specialists differ. For general practitioners the secondmajor source of satisfaction lies in the personal relationships they makewith patients and their families, while for specialists the second priorityis the satisfaction of solving problems, of getting a correct diagnosis, ofdoing a good job technically. Two contrasting quotations will illustratethese differences. A general practitioner said 'my main satisfaction ismaking people happier, they come to me and thank me for what I'vedone . . . I'm a grandfather doctor . . . I've developed relationships withthree generations.' A radiologist said, 'divorcing it from people andlooking at it as a clinical problem that you are dealing with and solving,1 find is the most interesting part.'

30 Bates

Table 2 What is the main satisfaction you receivefrom the practice of medicine?

GeneralPractitioners Registrars Specialists%(N = 51) %(N =30) %(N = 24)

31

26

20

40

34

6

14114

nilnilnil

nilnilnil

Helping people, giving a service,getting them better, seeingresults, having patients grateful 35

Solving problems, correct diagnosis,diversity and variety of work 12

Personal relationships with patientsand families 24

Doing a good job, overcomingdifficulties, technical aspectsof job nil 23 20

Freedom and autonomy, beingown boss

High status in communityNo real satisfaction

100 100 100

Stresses in medical practiceThe answers to the question: 'What is the greatest stress medicine placeson you?' were considerably longer and more emotional than the respon-ses to the question on satisfactions; this is hardly surprising since all ofus find it easier to complain about something than to analyse our satis-factions. The answers to the questions are summarized in Table 3.

General practitioners' stressesAlthough all doctors spoke of shortage of time, this was the mostimportant stress for general practitioners. The long hours of work, thefatigue, and the fact that medicine is a lifestyle rather than an occu-pation, were comments that came up in almost every interview. Indeed,the whole working lives of most of these general practitioners seemedto have been passed in a tense and rushed atmosphere. They said thatthere was not enough time available to do the work as well as they wouldlike to do it, and their enjoyment was hampered because they knewthat it should be done better. They were frustrated because they couldnot talk adequately to their patients, they were tense almost continuallybecause they were regularly behind schedule, and because the waitingroom seemed to be always full. 'I can't stop, say I'm tired, I've hadenough, and go away . . . I just have to see all the people that are waiting,even if it takes till 9 o'clock at night, and then I have to do the callsthat have been promised' is a typical comment. They felt continually


Table 3 What is the main stress medicine places on you?

GeneralPractitioners Registrars Specialists%(N = 51) %(N = 30) %(N = 24)

Physical overwork, fatigue, lackof sleep 47 24 30

Responsibility to see nothing goeswrong, fear of missing somethingserious, doing something stupid,uncertainty about diagnosis

Decision-making in crisis situationsHospital politicsStudy for exams and keeping up

with new knowledgeConflicts between home and jobLooking after dying patientsPractice problems, running a

business, partner disagreements

255

nil

nilnil

8

15

100

30159

994

nil

100

248

13

51010

nil

100

tired, were unable to relax when they v'ere on call, and had, for years,been tied to a telephone. In recent years, with the acceptance of depu-tizing services, things had improved, but in Australia, as in Britain, theage of general practitioners in the inner cities tends to be higher than inother areas, and for older doctors, even a deputizing service at nightsand weekends did not make up for having to work about 12 to 14 hourson a normal day. They did acknowledge that they are now very wellpaid for their work (in Australia, doctors are in the top 2 per cent ofincome eamers), but argued that this did not make up for the lives theyhad to lead. 'Human nature being what it is, if you permit them to doso the public will kill you. The incidence of illness with no waming isextremely low. The incidence of patient demand is extremely high andthe difference between the two adds up to the stress the doctor is placedunder.' Country work was a particular problem in this regard, whenthere was no other doctor within reasonable distance. This has improvedlately, but is still a problem in Australia where distances are great.Perhaps one doctor's comments will give an idea of the problems 'whenyou had a woman having a baby and she had a haemorrhage and youwere completely on your own and you knew that the nearest help was150 miles away . . . the stress is tremendous because everything dependson you . . . you have to make very quick decisions in situations whichcannot be foreseen.'

32 Bates

Registrars' and specialists' stressesRegistrars and specialists also felt the lack of time as a problem, butwere able much more easily than the general practitioner to cope withit because they were in hospitals where someone else took over whenthey left. They did work late on many occasions when they felt it wasimportant that their own knowledge of the patient should be used,rather than that another doctor should begin treating without the de-tailed acquaintance the first doctor had with a particular problempatient. But there were limits to such work, and calling back to the hos-pital on weekends was felt to be voluntary and therefore not so muchof a strain.

If one examines Table 3, it is clear that the stresses of 'responsibility'and of 'decision-making' are closely related. If one totals these twostresses, it becomes clear that this is the major stress for these doctors,though it clearly became less as the doctor grew in experience (and age).The registrars were concerned because they found themselves, reasonablyoften, in situations where they were out of their depth, but had to cope.'One is aware of one's mistakes and that worries you . . . misdiagnosis,missing, for example, an intestinal obstruction, or a fracture in casualty. . . often there's no check on your work . . . you are the end of the line.'And though many mistakes are trivial, they can be major and 'the resultscan be appalling and then the guilt is tremendous'. The greatest stressoccurs when registrars find themselves as the person at the end of theline, with the responsibility of making the final decision. Newly quali-fied specialists commented that it was easy forjunior doctors to criticizedecisions, but it was much harder to be in the position of actuallyhaving to make them. 'When you're the one with the actual responsi-bility, that's the hardest thing . . . residents think it's terribly easy todecide because they're not responsible for the patient . . . if I assistanother surgeon at an operation, I don't worry about that operation, Iassist him, try to help as best I can. I can quite enjoy that operationbecause it's not my responsibility, because you know if it bleeds likestink during the night, it's not your fault — so that's the big thing,responsibility.' This, of course, does not help the patient, but it doesexpress the feeling of the doctor and explains some of the incompatiblereactions between patients and doctors when things go wrong.

Emotional stress of medical practiceMost wives rated relatively high the conflict between a doctor's workand his family life, but it is noteworthy that the doctors themselves,over-occupied and preoccupied at work, did not rate the conflict be-tween work and home as a particularly important one; it was the wiveswho described it in graphic detail. The impact of the emotional distress


the doctors have trained themselves not to recognize is shown by theanswers to the question 'are you (is he) generally emotionally drainedwhen you (when he) comes home from work?' Table 4 details theresults.

Table 4 Doctors and their wives' response to the question: 'Are you(is he) emotionally drained when you (when he) come(s)home?' (%)

General practitionersGP's wives

RegistrarsRegistrars' wives

SpecialistsSpecialists' wives

Yes,frequently

2084

3075

1580

Sometimes

650

5020

7015

No,Never

1516

155

155

Total

100100

100100

100100

The figures show that 4 out of 5 general practitioners' wives, but only 1out of 4 of the general practitioners themselves, regarded them as 'fre-quently' emotionally drained; the proportions of registrars and specialistsand their wives are similar. The wives described how they knew thattheir husbands were emotionally drained: 'he becomes hard to talk to,his concentration goes'; and 'I don't know what he does at work, I justsee what he's like when he comes home — he's tense, edgy and irritable'.'He doesn't really start relaxing till about lunch time on Sunday, and by7 o'clock he's keying up again', and 'I don't dare to speak to him aboutthe children or my problems, he just bites my head off. The wives saidthat in order to keep the household peace, they had to ensure thatthe house was tidy, the children quiet, that no problems were mentionedeither by the wife or children ('don't worry your father'), and that thewife devoted herself completely to meeting her husband's needs whenhe came home. Most of the general practitioners saw themselves asphysically tired rather than emotionally drained, but the wives disagreed,and said that their husbands behaved quite differently when they weremerely physically tired after, say, a day's physical exercise. Those doc-tors who were prepared to accept that they were under emotional stresssaid that after supporting worried people all day, something must ruboff on the supporter; they were not in the mood to be very sympatheticwith their wives and children if they were greeted with more problemswhen they arrived at home — home was supposed to be a sanctuaryfrom their workaday problems. This is of course not always possible,given that wives and children are human too, and the discrepancy

34 Bates

of needs often became a source of friction and frustration for allparties.

The registrars and hospital specialists seemed to be more aware oftheir own emotional condition and its causes than the general practi-tioners; the registrars spoke of the emotional draining that resultedfrom dealing with critically or terminally ill patients and their relatives,and from having to make difficult decisions many times a day, oftenwith inadequate time to think about the consequences. 'The moreequivocal a decision is, the more draining it is.' Probably because theregistrars and many of the specialists were younger than the generalpractititioners in the sample, they had not yet taught themselves tosuppress all their own natural emotions and were still prepared to recog-nize their own reactions. They described the experience in terms of atotal amount of emotional energy that they had available, and suggestedthat when it was emptied, they needed time to recharge themselves.One woman doctor who had recently finished working in a paediatricunit, said that for her the time came when more than four children diedin a day — she then felt totally emptied and could no longer go onworking until she had had a break.

Organizational stressIn previous papers, I have reported on stress levels of hospital doctors,nurses, and medical and non-medical hospital administrators." Inthat study, the highest stress scores on Kahn's questionnaire^* werethe intems' scores on 'feeling unable to infiuence administrative decis-ions' and 'feeling that your job tends to interfere with your family life'.At that time we wrote, 'interns feel powerless vis-a-vis the administrators;they cannot reconcile their work and family responsibilities; theyare overloaded with work, and they are concemed about the quality oftheir work.' In the present study, I used the same questionnaire withthe registrars and specialists. (The questionnaire could not be used forgeneral practitioners who work as independent practitioners, as it isdesigned for organizational personnel.) Table 5 shows the results. Againthe three top-ranking stresses are as they were for the intems. Thus overa 4-year period, with different samples and different age groups fromthe doctor population, the rank order of scores is identical.

Discussion

Although there are many satisfactions in the practice of medicine, thereare concomitant problems and stresses for practitioners, and these havebeen under-emphasized in the literature.


Table 5 Highest three stress level mean scores. (Intems surveyedin 1972; Registrars and Specialists in 1976)

Interns Registrars Specialists(N=43) (N=30) (N=21)

Feeling that your job interfereswith your family life 3.9 3.5 3.2

Not having sufficient time orresources to do all the thingsyou feel should be done 3.7 3.3 3.5

Feeling unable to influenceadministrative decisionsand actions that affect you 3.4 3.2 3.0

Mean scores can only be comparative, as population norms are not available. USAadministrators score means of 1.7, NSW administrators score 2.2. The average for all questionsscored by doctors is 2.4. Hence doctors score above the mean of administrators as a whole andthese three questions have scores indicating high stress.

The major sources of strain for doctors were a shortage of time, res-ponsibility for people's welfare, and the inevitable presence of illnessand death. Some role stress is, of course, inevitable in any profession,but if that stress is too great, or located in the wrong area, it can havea serious impact on the clients of that profession. I would argue thatsome of the stresses described by respondents in this survey do havedysfunctional consequences for both role-partners in the doctor-patient relationship.

For genera! practitioners, the problems are complex. Ironically, partof the stress general practitioners felt is the reduction in their role asdoctors, without a commensurate reduction in their workload. Theyfelt that their status has been reduced, both among their medical peersand relative to the rest of the community. They are no longer the re-spected elite, one of the few people with higher education; they areassailed by a very bad press. A main source of satisfaction, the contin-uing relationship with patients, has been eroded because communitiesin cities are no longer stable and it is harder to make relationships overa long period with families in a particular urban area.

Professionally, general practitioners have fared badly. They have beenfrozen out of hospitals, they can only do very minor surgery in privatehospitals, and even maternity care, once a source of major satisfactionin general practice, is now mostly done by specialists in teaching hospi-tals. At the same time, general practitioners are asked by patients to dothings for which they feel untrained; they do not feel easily able to copewith the emotional problems their patients bring them with increasingfrequency. On the other hand, they are asked to refer their patients onas soon as a problem becomes interesting (for the doctors); which leavesthem, as one said, to act as semi-skilled social workers about 80 per cent

36 Bates

of the time. At the same time they still have to take all the risks ofmedical practice: the risk of missing a serious problem, or of treating aproblem in the wrong way, because they had lost their alertness whiledealing with so much that was trivial. Indeed, on listening to the tapesit seemed that general practitioners were mourning for a life they hadexpected but which had never come, one of challenge and interest andthe opportunity to investigate interesting problems; they were seriouslydisappointed in their work and their current role, and found their maincompensation in their very high income for which they are frequentlyattacked by the media. For registrars and specialists, the issue of mis-takes loomed very large. Mistakes are an occupational hazard in anyrole, but doctors' mistakes can have more serious, visible consequencesthan most others.

Until recently, it was only among doctors themselves that some ofthese issues had been discussed, so that patients would not lose confi-dence. But now doctors are beginning to write more openly, acknow-ledging that 'not some, not most, but all doctors, atone time or another,make errors. That is the nature of medicine; it isn't an exact science'.^'*Another doctor says that doctors are really not more rushed thanmany other people in society today, but that what distinguishes medi-cine from most of the other high pressure activities is 'the continualneed to make rapid decisions on which lives may depend, often on thebasis of inadequate information. In the course of a busy morning's worknumerous decisions are made and action is planned on the basis ofprobabilities, and only the most likely cause for any symptoms can beconsidered and followed up. This means that much of the time thedoctor is left wondering if he should not have looked more closely forsome other possibilities, and I suspect a great deal of anxiety and dis-illusionment is built up over the years by only being able to deal withthe surfaces of things.'^'

Specific to work in health services is continuous contact with disease,suffering, distress and death. I have reported elsewhere^^ on theproblems doctors face in making decisions in critical illness, but therecan be no doubt that there is a considerable emotional impact on mostdoctors when they have to tell a patient, and a family, that they arefaced with a very unpleasant, and perhaps a fatal, condition.

The impact of these stresses falls, of course, not only on the doctor,but also on the doctor's family. The detailed analysis of the family livesof the doctors interviewed will be the subject of a future paper, and thiswill demonstrate very clearly how short-changed most wives feel in theirexpectations of marriage to a doctor.

Many doctors spend the bulk of their working lives in situationswhich provoke anxiety and other emotional stresses, and the conse-


quences fall both on patients and on doctors' own families. Social scien-tists complain that doctors distance themselves from patients' problems,but this is hardly surprising.

Indeed, it is clear from the above research that doctors are often un-able to distance themselves from the emotional stresses inherent in theirwork, and that they and their families suffer accordingly. A great dealis required of families of doctors, as will be shown in later papers, ifthey are to survive intact the stresses of medical practice. As Ellard says,'such personal and family relationships as we have managed to accumu-late during the preceding years have to be secure if they are to withstandthe hours of separation, the changes which have occurred within us, andthe tensions and irritabilities which most of us show in this early post-graduate period.'"

Patients, of course, suffer too when a doctor is over-anxious orstrained. Indeed doctors' own inability to cope with stress may verywell be one reason for the high prescription rates of tranquillizing drugs.It is therefore probably futile for patients to demand that doctors shouldteach them to relax, to cope with stress without pills, to spend moretime in counselling them and helping them to analyse their problemswhen it is very clear that the overwhelming majority of doctors havenot been able to do this for themselves or their own families. It there-fore becomes increasingly important to teach doctors how to managetheir own emotions.

Yet in spite of the increasing importance which studies in behaviouralscience are being given in medical education, there is still little emphasisin these courses on teaching doctors what emotions they may expect tofeel in their practice of medicine. No systematic attention is paid to theneed for doctors to receive regular counselling, to put themselves intothe position of helpee rather than helper. There is no structure withinthe medical profession which would make this an ordinary, easily acces-sible part of medical education and medical practice. When a doctor cansay 'I was quite surprised at my own reaction to caring for a dyingpatient, but no one has ever discussed this with me', it is surely not toofar-fetched to suggest that such feelings of helplessness, frustration, andanger will affect the care that the doctor can give the patient, the emo-tional resources that are left to the doctor, and the level of stress of thedoctors and their families. By the time the doctor has become every-body's prop (except perhaps his wife's), it is too late to change attitudesdeveloped throughout training and practice. A rethinking is needed ofthe role, in medical training both before and after graduation, of studiesin self-analysis, of techniques of anxiety reduction, and of discussion ofthe personal risks to doctors' family lives and quality of life. Since thefuture of medical practice looks increasingly technological, such studies

38 Bates

assume increasing importance if the humanity as well as the science ofmedicine is to be preserved.

It is not possible to give an answer, in pseudo-statistical terms, to thequestion 'What is the ratio of doctors' satisfactions to stresses?' Yet theanswer to this question is important, because doctors' stresses do havean impact on patient care as well as on doctors' own health and theirfamilies' welfare. Doctors use a number of methods to reduce the stres-ses they feel. They repress their own emotions, they laugh about seriousproblems, they increase the emotional distance between themselves andtheir patients,^'' they use alchol and drugs, they sometimes resort tosuicide, and they frequently retreat into themselves because they havenothing left to give to their families. In addition, doctors find a greatdeal of difficulty in verbalizing their own emotions. Because they aresupposed always to support others, they are uncomfortable in the roleof the person needing support. '^"" There needs to be more carefulanalysis of the stress inherent in the doctor's role, so that methods canbe devised to enable doctors to cope effectively with that stress. Patientsshould gain considerable benefit from such a change.

Revised version School ofHealth Administrationreceived: October 1980 University of New South WalesAccepted: April 1981

Notes

1. I. lllich. Medical Nemesis, London: Calder & Boyars, 1975.2. R. Carlson, The End of Medicine,New York: Wiley, 1975.3. P. Ley and M. S. Spelman, Communicating with the Patient, London: Staples

Press, 1967.4. H. Waitzkin and J. S. Stoeckle, 'The communication of information about

i}lness\ Archives of Psychosomatic Medicine, 8 (1972).5. M.J. Bloor and G. W. Horobin, 'Conflict and conflict resolution in doctor/

patient interactions', in Cox and Mead, A Sociology of Medical Practice,London: Collier-Macmillan, 1975.

6. 1. Zola, 'Medicine as an institution of social control', in Cox and Mead, A So-ciology of Medical Practice, London: Coilier-Macmillan, 1975.

7. B. Ehrenreich and D. English, Complaints and Disorders - the Sexual Politics ofSickness, Old Westbury: Feminist Press, 1973.

8. P. Boreham, A. Pemberton and P. Wilson (eds). The Professions in Australia,St. Lucia, Queensland: University of Queensland Press 1976.

9. R. Bucher and A. Strauss, 'Professions in process', American Journal ofSociology,66 (Jan. 1961), 325-34.

10. E. Freidson (ed.). The Professions and their Prospects, Beverley Hills: Sage,1973.

11. E. Freidson (ed.) Profession of Medicine, fiew York: Dodd Mead, p. 10.


12. Ibid., p. 350.13. D. A. Sargent, V. W. Jensen, T. A. Petty and H. Raskin, 'Preventing physician

suicide: the role of family, colleagues, and organized medicine'. Journal of theAmerican Medical Association, 237 (2) (1977), 143-5.

14. E. M. Waring, 'Psychiatric illness in physicians: a review'. Comparative Psy-chiatry, 15(6) (1974), 519-30.

15. D. de Sole, P. Singer, S. Aronson, 'Suicide and role strain among physicians',International Journal of Social Psychiatry, 15 (4) (1969), 294-301.

16. R. M. Murray, 'Psychiatric illness in male doctors and controls: an analysis ofScottish hospitals in-patient data', British Journal of Psychiatry, 131 (1977),1-10.

17. P. Williams, 'Doctors under stress'. The Listener (28 Feb. 1980) 270-1.18. G. Vaillant, J. Brighton, C. McArthur, 'Physicians' use of mood-altering drugs'.

New England Journal of Medicine, 282 (7) (1970), 365-70.19. W. A. Cramond, 'Anxiety in medical practice — the doctor's own anxiety',

Australia and New Zealand Journal of Psychiatry, 3 (1969), 324.20. D. Maddison, 'Stress on the doctor and his family'. Medical Journal of Australia

(31 Aug. 1974), 315-18.21. E. M. Bates, J. Hinton, T. J. Wood, 'Unhappiness and discontent: a study of

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Documents

Doctors and their spouses speak: stress in medical practice