Stress management

“It’s not stress that kills us, it’s our reaction to it” – Hans Selye

There is no panacea for stress, but you can become very skilled at recognising it, managing the causes and taking control of howyou respond. You and your patients will be grateful.

By the end of this section I hope that you will have a greater understanding of these skills, be motivated to start using them and startdeveloping your own search for making your life less stressful.

There are three sections:

Understand.Recognise.Act.

Understand

First, the unavoidable doom and gloom bit.

Stress is a modern reality.It is a big problem.As clinicians we know this only too well from our own experiences, and those of our colleagues and our patients.

The most recent NHS staff survey, conducted in 2014, showed that more than 30% of junior doctors state they had experiencedwork-related stress in the past 12 months (http://tinyurl.com/LMT-NHS-staff-survey).

The situation is worse amongst GPs and consultants.

The good news is that you CAN learn to manage stress. It CAN be different.

How you respond to the same stressors will vary at different times – think about times when you have been on-call, sometimesdespite the relentless pressure you can manage and have time for some banter with your colleagues.

Equally the same stressors will produce a variety of levels of stress in your colleagues.

In this section I want to help you to understand some more about what stress is, how you respond and why; then what can you do tochange this.

But first, consider this insightful story from a London GP shared at a leadership away day.

Managing your stress is important

Stress is not unique to medicine. But excessive work, dealing with patients’ suffering, fear of mistakes and a clustering of certainpersonality types in clinicians makes it more common. With such high stakes in the jobs we do, it is more important to recognise andmanage (BMJ 2009;338:b1368).

You owe it to yourself.

After all your hard work to get here you need to be able to enjoy your valuable work, and the time you spend outside of it.It matters because a proportion of doctors experiencing prolonged stress will develop more serious problems such asdepression, burnout and substance misuse.It matters to patients – stressed-out unhappy doctors can make poor decisions that affect patient care.

A recap of some basic science

I had a life-changing surgery a couple of years back.I was a registrar at the practice there and then was full time for about 3 years. I have always been a bit neurotic. Although I lovedseeing patients, I found it hard to manage the uncertainty of what might happen when they left my room. In my mind every patientwas on the verge of dying until proven otherwise and I would be responsible. I was finished at the end of each surgery, dizzy.I remember a day, it was bright and sunny, June I think, I was wearing a short sleeve blue shirt, I don’t know why I remember that.I was having a good surgery that day with a lot of patients I had been treating coming in for advice or follow-up. Towards the endof the surgery it dawned on me that most patients who come to see me are not going to die or be diagnosed with cancer byanother doctor. And I was actually doing a job that my patients valued. I was OK.I felt like a massive weight lifting off me. It sounds really simple, or maybe I’m really simple and everyone else discovered thisyears ago, but this one realisation has changed my life. I’m much happier now, less stressed out. I have put up a picture of asunny day on top of my screen to remind me at my new place.

There is so much we don't know in medicine that could make a difference, and often we focus on the big things, and the little things get forgotten. To highlight some smaller but important issues, we've put together a series of pearls that the Red Whale found at the bottom of the ocean of knowledge!

There are two instinctive responses to stress: fight or flight and the ‘General Adaption Syndrome’.

Fight or flight

This is a short-term survival response to shock or stress.

It may help us deal with a life-threatening event, or an approaching mammoth, but if left unmanaged in everyday situations it canzap our energy and make us anxious or aggressive.

Think of an aggressive patient or giving a presentation. Some degree of fear is appropriate, but successfully managing this situationrequires control, confidence and a clear head.

The General Adaptation Syndrome

This is a response to long-term, repeated exposure to stress and has three distinct phases (Seyle, 1936):

Alarm phaseThe first acute reaction to the stressor, fight or flight.E.g. your first unsupervised on call, your first presentation in front of a group.

Resistance phaseAdapt and cope with stressor.Your body can’t keep up the resistance indefinitely, unless you identify ways to manage the stressors, and yourphysical and emotional reserves run out.Learning to mange your on- call, receiving positive feedback and practising your presentation skills.

Exhaustion phaseWhen your reserves are depleted.Maybe you are burnt out. We will return to this.

What makes an event ‘stressful’?

A widely accepted definition of stress is “a condition or feeling experienced when a person perceives that the demands exceed thepersonal and social resources the individual is able to mobilise” (Lazarus & Folkman, 1984).

When we encounter a stressful situation, we make two judgements, often these are unconscious:

Is the situation threatening?Do we have the resources to meet the perceived threat?

If a perceived threatening situation exceeds our available resources we feel it as stress and often our response is then outof control.

If we let it go unchecked, it is uncomfortable, can lessen our performance and ultimately may have long-term consequences.

However, if we recognise it – we have an opportunity to do something about it!

One final bit of science before we move on to recognising stress in ourselves (and others)!

Stress and performance

Two psychologists Robert Yerkes and John Dodson defined the relationship between pressure (arousal) and performance in 1908.

Low pressure can lead to boredom and low performance, where as high pressure can lead to high levels of stress and anxiety alsoleading to poor performance. Both are equally as demotivating. In the middle is peak performance, described by some as ‘flow’.

Here is a visual representation:

So pressure per se is not a bad thing. We all need some – you would not be sitting here now if your life didn’t have some pressure.

Recognise stress

Do you know why and when you get stressed?

Are you sure? You might be surprised!

You may also be surprised when a little pressure is helping you! Let’s think about this.

Stress has symptoms

I know you know this!

You share this with your patients all the time.

But do you spot it when it is happening within you?

I am going to risk the inevitable cries of ‘teaching grandmothers to suck eggs’ because I am willing to bet that most of us tune outthese symptoms when we start to feel them ourselves:

Reflect on times in your life where pressure has been a positive thing?Now think about times when pressure became unmanageable?What was the difference between the two scenarios?

So, pretty unpleasant.

Day-to-day stress

The most effective way to sort out where your stress is coming from is to keep a ‘stress diary’. Doing this for a typical working weekwill give you real insight into where your stress is coming from.

Essentially it involves tracking changes in your stress levels and happiness levels so that you can identify triggers and protectivefactors.

I have often used this strategy with patients with enlightening results. You can find a copy and instructions of how to complete astress diary in an adapted version in the Appendix.

Here is an example to get you going.

In this example, the doctor feels stressed getting her kids out in the morning and when she was not given sufficient time to remove acoil, although she remained pretty upbeat then. The surgeries were moderately stressful but also enjoyable. However, the doctor’sstress and unhappiness levels were highest because of a doctors meeting.

This persisted for a few hours, even when she got home!

Fortunately, she had taken up playing the guitar again and following this diary started working up a plan with the practice managerand another doctor to resolve conflict amongst doctors at the practice.

In other examples it may be coping with clinical complexity or workload. You may be able to identify with aspects of these scenarios.

Symptoms of stressFrequent headachesGastrointestinal symptomsShaking and tremorDry mouth and sweating (especially in meetings)Excessive sleeping or insomniaPersistent difficulty concentratingIrritability and angerDifficulty making decisionsWeight loss or gainSocial withdrawal and avoidance behavioursObsessive and compulsive behavioursFrequently feeling overwhelmedFeeling muzzy headedDrinking and smoking too much

Monday 5th June Stress score ( /10) Happiness score (/10)

Activity Reason for change instress or happiness

0700 3 7 Getting ready

0800 9 5 Getting kids ready Bags not packed

0900 7 7 Morning surgery Midwife finished labforms!

1000 5 9 Morning surgery Mrs P 2ww referralcame back clear

And then later the same day…

1500 9 7 Coil removal No double booked(again!)

1600 6 7 Afternoon surgery

1700 8 8 Afternoon surgery Two extras

1800 9 4 Practice meeting soon Senior partner

1900 9 3 As above Senior partner

2000 9 4 Going home Senior partner

2100 7 7 Dinner With boyfriend

2200 5 8 Playing guitar Bob Marley

Act

In the last two sections we have described how and why stress is more prevalent in doctors, that it can be both damaging and alsomotivating, and that recognising it can lead to finding techniques to manage it.

There are abundant ways that managing stress can be approached, from the downright practical, e.g. checking you have enough labpaper (or hiding it from the midwife as I do), to optimising your physical condition or discovering your spirituality.

Any approach will require some self-awareness and a commitment to want to improve things.

Decide on the main type(s) of stress

An interesting approach to deciding which techniques to use to manage stress is to use the classification developed by Karl Albrechtin 1986 who described stress as falling into one of four main categories:

Time stress.Anticipatory stress.Situational stress.Encounter stress.

In the table, we consider each in turn – what causes them, how to spot them and what you can do about them!

There is much more information about many of the techniques recommended in other areas of this handbook and articles that maybe particularly useful in helping you to build the skills you need include:

Understanding yourself.Time management.Delegating effectively.Resilience.Difficult conversations.Improve my negotiating skills.

Take some time to think about how you would tackle these issues, or how you would advise a colleague if they came to you forhelp.

Time stress

What is it? How to spot it? What can I do?

This is part of every doctor’s jobdescription – as GPs we manage theworld in 10-minute chunks but oftenrealise this is not enough!Worrying about time and the lack of it isan acute stress and can wear you down.This is probably the most common stressthat we all face.

Being consumed by worry aboutdeadlines.Always rushing.Feeling trapped or hopeless.

Learn and practise timemanagement techniques.Prioritise.Learn to say ‘no’.Delegate.Planning, using lists and working onpersonal organisation can help.Influence the environment you workin.

Anticipatory stress

What is it? How to spot it? What can I do?

Stress caused by worrying about thefuture. Either:

A specific event.A nebulous fear (may then berelated to anxiety).

This type of stress is about ‘lack of control’– we can anticipate and prepare for thefuture but we can’t fully control it.

Sense of doom.Feelings of hopelessness.Ruminating.

Meditation and mindfulness help tofocus on the here and now.Positive visualisation and imaginingpositive outcomes are effective.Analysing and ‘scoring’ all possibleoutcomes and developing realisticcontingency plans can give agreater sense of control.

Situational stress

What is it? How to spot it? What can I do?

Burnout

When your emotional and physical reserves have been expended, you may be burnt out.

The phrase originated from rocket science in the USA to describe a rocket that is still moving forward and apparently doing its job,although it is completely devoid of fuel and in every other way, useless.

It occurs more frequently amongst professional people in caring professions and is associated with encounter stress, lack of control,chaotic working environment, conflict of values and a work–life imbalance (Lancet 2009;374(9690):595).

Some of this might be resonating with you. It is important to recognise the features of impending or actual burnout in yourself orcolleagues.

The principle features of burnout are:

Dissociation with work.Dreading going to work.Having low energy and little interest.Being easily irritated.Frequently thinking of leaving or changing roles.

If you feel you are experiencing the symptoms of burnout it is important to get help. There is a link to a ‘burnout inventory in theResources box below’.

There are a number of highly skilled, confidential services for doctors. Your appraiser, Deanery and the BMA will all know about localresources. There is a link in the Resources box that lists a number of national organisations.

Looking after yourself is vital. Remember what a giving and valuable job you have. When you have done your day’s work, stop,leave and do something for yourself.

Remember that preventing stress in the first place is key – if you haven’t read the chapter on ‘Resilience’ read it now.

This is ‘here and now’ stress when youfind yourself in a threatening situationover which you perceive you have little orno control.Typical situations might include:

Conflict.Aggression.Public speaking, for some.

Typical ‘fight or flight’ signals – recogniseyours!E.g. fast heart rate, nausea, panic,muscles tense.

Learn to spot your warning signsand anticipate situations wherethese stresses might occur.Use relaxation techniques, e.g.breathing, progressive musclerelaxation.Learn and practise negotiationskills.Read about emotional intelligenceand learn and practise how tocontrol your emotional responses.Move away from the situation for awhile – take a walk, clear yourhead, then return, others may needto do the same.

Encounter stress

What is it? How to spot it? What can I do?

This occurs during interactions withspecific people or groups.For doctors this may be colleagues orspecific patients or types of patient.It can also relate to emotionallychallenging clinical issues especially ifthey strike a personal chord with our ownlives

Avoidance.Heart-sinking feeling.Anger.Detachment.Appearing cold and aloof.

Re-examine your perceptions.Focus on the issue, not the person.Recognise your own and othersemotional reactions and learning tocontrol them can help the stressreaction.Re-visit communication skills –skilfully convey how the encounteris making you feel.Re-read about ‘heart sink patients’if patient issues are a particularissue.You may need a holiday!

Managing your stressDoctors are prone to stress and burnoutWe are not always good at recognising and acting on it.Stress is experienced when there is a perceived mismatch between the demands of asituation, and the resources available to cope.Learning to recognise the features of stress will allow you to control your response anddevelop a toolbox of resources.The ultimate consequence of stress is burnout – it is important to recognise if this ishappening to you.Looking after yourself is vital. After a days work, stop and go and do something foryourself.

Complete a stress diary, found in the Appendix, for one week – reflect on the outcome. Canyou see areas you could change?Pick one of the ‘types of stress’ that you commonly experience and start to work on some of theskills that might help you to manage these stresses.If you have identified the symptoms of burnout in yourself or a colleague, get some help –today.

ArticlesA really useful book if you want to read more about stress:Lazarus RS & Folkman S (1984) Stress, Appraisal and Coping. Springer.To read more about the 4 types of stress:Albrecht K (1986) Stress and the Manager. Simon and Schuster Inc.A really useful article if specific patients or groups of patients are causing you stress:Groves JE (1978) Taking care of the hateful patient. NEJM 298(16):883.WebsitesLink to a ‘burnout self test inventory”:www.mindtools.com/pages/article/newTCS_08.htmA useful list of contact details for doctors experiencing any mental health issues:www.gmc-uk.org/concerns/11551.asp

We make every effort to ensure the information in these pages is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and this should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check drug doses, side effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability for loss of any type caused by reliance on the information in these pages. GP Update Limited April 2017

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