Stress and the obstetrician.

There is no doubt that the specialty of obstetrics and gynecology lends itself to occupational stress, perhaps more than any other specialty. Demands in regard to malpractice claims and increasing premiums, the need to see increasing numbers of patients with decreasing reimbursement, and Health Insurance Portability and Accountability Act of 1996 requirements certainly apply to all physicians and are part of the equation. However, the unique nature of the obstetric patient requires consideration of both mother and fetus, making the balance of management decisions sometimes precarious, unpredictable, and often at 2:00 AM; 76.5% of American College of Obstetricians and Gynecologists fellows have experienced a malpractice suit at least once during their career. The American College of Obstetricians and Gynecologists even has published a committee opinion on stress and malpractice. (1) The psychological distress and emotional impact a medical liability case has on an obstetrician's personal and family life and medical practice can be tremendous, particularly if it takes several years to resolve. With this constant sword of Damocles above their heads, the issue of occupational stress for obstetricians seems a career-long issue.

In this issue of Southern Medical Journal, Promecene and Monga (2) evaluate occupational stress among obstetrician-gynecologists in an urban practice setting. Thirty-three percent of the respondents in the study reported significant amounts of stress, with no significant difference in measurements between physicians of different gender, practice size, or time off. Previous studies have noted stress was also common during residency training in obstetrics and gynecology. (3) If these concerns have already been identified during residency, there needs to be an effort to address them during training and throughout an obstetrician's professional life.

Proper diet, exercise, sleep, relaxation, and meditation are all steps toward reducing stress in daily life and probably even suggested by obstetrician-gynecologists to their own patients. It is important that all physicians have realistic expectations for balance between their professional and personal lives, because with some physicians (including obstetricians), too often the lines blur between profession and obsession. Development of peer groups for ongoing education and discussion may address common areas of stress and more effective stress management.

The role of postresidency mentoring may be a potential method of support. Finding an outstanding mentor can be helpful for younger physicians; being a mentor can certainly provide equal benefit as well in terms of assessing one's own perspective of the balance between personal and professional demands. The challenge and expectations of the clinical practice of obstetrics-gynecology (or any specialty) may be well established in residency. However, once in practice, younger physicians may find that the issues of time management, hospital staff politics, and the business aspects of medical practice are complicated stressors for which a mentor can provide guidance in terms of valuable insight and experience. Mentoring is a common practice in the corporate world--why not in medicine?

The current threat of the malpractice system as it impacts obstetrics has already created a domino effect in many states; physicians may be dealing with financially troubled insurance carriers that drop them from coverage after a settlement, unless they are fortunate enough only to have their premiums increased. Some obstetrician-gynecologists are simply going "bare" and waiting for the statute of limitations to expire on a potential malpractice case. The ongoing stress and strain of this aspect of obstetric practice only increases daily in states where tort reform is long overdue and outrageous awards are like a runaway train. What of the obstetrician late in his or her career who desires to transition out of obstetrics and yet faces the prospect of an exorbitant tail coverage payment? County and state medical societies need to address this issue to support local obstetrics and gynecology care; any legislation addressing the current malpractice crisis will be another major solution that may have an immediate impact on occupational stress. Sleep deprivation has always been part of obstetrics; the suggestion of a laborist as an alternative may make the specialty more appealing and less stressful. (4) Until the 2:00 AM delivery affecting our rapid eye movement sleep is prevented, however, the other proposed alternatives are far more realistic goals.

Accepted May 8, 2003.

References

(1.) American College of Obstetricians and Gynecologists. Coping with the Stress of Malpractice Litigation (Committee Opinion No. 150). Washington, DC, American College of Obstetricians and Gynecologists, 1994.

(2.) Promecene P, Monga M. Occupational stress among obstetrician gynecologists. South Med J 2003;96:1187-1189.

(3.) Schneider KM, Monga M, Kerrigan AJ. Stress in residency: Reality or myth? Am J Obstet Gynecol 2002;186:907-909.

(4.) Weinstein L. The laborist: A new focus of practice for the obstetrician. Am J Obstet Gynecol 2003;188:310-312.

Thomas P. Connolly, DO, FACOOG

From the Department of Obstetrics and Gynecology, Marshfield Clinic-Wausau Center, and the Department of Obstetrics and Gynecology, University of Wisconsin, Wausau, WI.

Reprint requests to Thomas P. Connolly, DO, FACOOG, Department of Obstetrics and Gynecology, Marshfield Clinic-Wausau Center, 2727 Plaza Drive, Wausau, WI 54401-4129. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association

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