Stress: a major problem for physician executives.

Stress is an integral and, indeed, a necessary part of our daily lives. We all work under stress to a greater or lesser degree. Without some stress, we would not function up to 100 percent of our capability. Some stress is necessary to bring out the best in us, to make us innovative, to make us meet deadlines and to continue to strive to improve our performance. However, if things get out of perspective and stress is not controlled or coped with in an adequate fashion, the inevitable result is a dysfunctional rather than a maximally functional state.

While the term "burnout" is of dubious value and means different things to different people, there is no doubt that inadequately controlled stress will lead to certain well-recognized consequences. Three stages have been identified[1]:

First Stage

* Failure to keep up to date. * Complacency. * Gradual loss of reality.

Second Stage * Accelerated physical deterioration-loss

of sleep, loss of energy, weight gain. * Graduated indifference to work situation

Third Stage

* Major physical and/or psychological

breakdown.

Bailey has described the physical signs of inadequate management of stress:

* Feeling of exhaustion and fatigue. * Inability to shake off lingering colds. * Headaches. * Gastrointestinal disturbances. * Sleeplessness. * Shortness of breath. * Skin complaints. * General aches and pains.

He also describes the psychological/emotional signs: * Touchy and irritable. * Easily moved to tears. * Apparently unprovoked outbursts of

anger. * Marked sadness. * Screaming and shouting. * Unwarranted suspicion and paranoia. * Avoiding commitments to caring. * Lethargy.

In order to cope with stress, it is important to understand where it comes from. Our stress comes from three basic sources :

* The environment. * Our bodies. * Our thoughts.

The environment, particularly the hospital environment at the moment, bombards us with demands to adjust. We must deal with time pressures, performance standards, various threats to our security and self-esteem, the huge changes that are going on, and the threats of much worse to come.

The second source of stress, our bodies, is physiological. There are stresses associated with the aging process, illnesses, accidents, and sleep disturbances.

The third source of stress is our thoughts. The brain interprets and translates complex changes in the environment and determines when to push the panic button: how we interpret, perceive, and label our present experiences and how we predict they will affect us in the future to either relax or stress us.

Situations or "states" can themselves be sources of severe stress -- for example, the stress of loneliness, the stress of relationships, the stress of depression and the obvious stresses of conflict, coping with change, and losing confidence. Perhaps one of the greatest and most embracing stresses affecting us is performance anxiety. In a given situation, it is usually easy to anticipate from past experiences how we're going to perform. However, in the current climate, with the introduction of so many changes and with such a new and different environment, performance in many spheres is a matter that clearly leads to anxiety and resultant stress.

Recognition of Stress

One of the difficulties in coping with stress is recognizing early symptoms so that they can be dealt with appropriately before they become a major problem. Most people find, if they think about it, that they tighten up certain muscle groups in their bodies, particularly at the back of the neck, but other muscle groups can also be involved. By the end of the day, many muscle groups have been involuntarily tightened and considerable damage has been done.

It is desirable to specifically "have a look at one's self" several times every day to determine whether muscle groups have been tightened or one's mouth has become dry and then set about rectifying the situation. Otherwise, one can reach the end of the day in a totally exhausted state, stressed to the extent that it is impossible to sleep properly.

Techniques for Reducing Stress

How a person goes about reducing stress is very much an individual matter. However, there are some well-known mechanisms.[3] The following list is not in order of importance, all the items may not be applicable to each person, and there are mechanisms not listed here that may be applicable:

* Don't allow things to drift for an extended

period. A person should be decisive;

making a decision, whether it is right or

wrong, will cause less tension and anxiety

than indecision.

* Attempt to identify your anxieties and

fears and work toward being objective in

identifying your problems.

* Having identified problems,

do not ignore

them. Seek constructive

strategies for

dealing with them.

* Seek moderation in

attention to detail.

Stress is often

associated with

attempts to attend

to every detail, no

matter how minute

or inconsequential.

Consequently, a simple activity may be blown out of all proportion, and overconcentration on details or overconscientiousness may obscure key factors and those requiring careful attention and take away the time available for dealing with important issues.

* Be realistic in your view of winning and

achieving. A person who places too

much emphasis on winning all the time

will experience continuous stress.

* Avoid judging yourself too harshly. You

should not expect more of yourself than

others do. At the same time, maintain a

high level of self-respect.

* Be willing to compromise and maintain

flexibility in approaching people and situations.

Rigidity in dealing with others

and with daily situations is a primary

cause of stress.

* Focus on present activities. Don't spend

time worrying about past events or possible

future occurrences.

So much for trying to reduce stress, but how do we deal with the inevitable level of stress that remains.

Coping Mechanisms 

* Time alone that is free of interruption

and demands of others. For a physician

executive, for whom exposure to the

demands of others is a constant daily

occurrence, this is particularly important

* Some form of regular exercise is critical

Remember that walking is as effective

as any other form of exercise.

* A well-balanced diet is necessary. This

means three meals a day, including

breakfast, a very important meal in facing

the stresses of daily working life.

* Finally, one needs some mechanism t

deal with stress when it reaches unacceptable

levels. A number of well

known and well-documented technique

are described in a number of publications

on relaxation and stress reduction

(see further reading).

Learning proper breathing techniques an how to associate them with relaxation, particularly muscular relaxation, will not only reduce levels of stress during the day, but also provide a very good aid to getting a good night's sleep. Whatever technique or techniques one decides on, daily practice is needed. Progressive muscular relaxation, meditation, visualization, self-hypnotics, and autogenics all have various degrees of difficulty and require varying degrees of commitment and practice. Many people find that breathing, combined with progressive muscular relaxation, is the simplest and most effective technique. Important points to remember are that the breathing must be through the nostrils, diaphragmatic, slow, and controlled.

It is important to learn some technique for coping with stress. If this can't be done satisfactorily through resource material, expert help from an appropriate health care professional should be sought.

References

[1.] Moran, E. "CEO Burnout: Shift Priorities to Manage Stress." Hospitals 64(9):67, May 5 1990.

[2.] Bailey, R. Coping with Stress in Caring. Carlton, Victoria, Australia: Blackwell Scientific Publications, 1986.

[3.] Greenberg, S., and Valletutti, V. Stress and the Helping Professions. Baltimore, Md.: Paul H. Brookes, 1980.

Further Reading

David M., and others. The Relaxation and Stress Reduction Workbook, Third Ed, Oakland Calif.: New Harbinger Publications, Inc., 1992.

Message, J. Dealing with Stress. Adelaide, South Australia, Australia: Griffin Press, 1989.

King, M., and others. Stress Theory and Practice. Marrickville, New South Wales, Australia: Grune and Straddon, 1987.

Hoff, L. People in Crisis. Redwood City, Calif.: Addison-Wesley Publishing Co., Inc. 1989.