Surviving in a world of change.

Physicians do not have the control, the income, the status, or the time that they once had. Such losses can create some miserable feelings--anger, sadness, resentment, shame, anxiety. In describing the increasing pressures on physicians, Wallen lists the physical reactions: "On a short-term basis, the body reacts to what it perceives as a threatening situation by secreting hormones that raise the blood pressure, increase the blood flow to the muscles by up to 400 percent, and speed up heart rate, metabolism, and breathing. This |fight-or-flight' response is accompanied by psychological symptoms, such as anxiety and anger."[1]

When unwanted change is thrust upon you, your feelings are hurt and you feel depressed. You may think: "How could they jerk me around like that--someone who is as good as I am, as important to the organization as I am. How could they? They shouldn't be able to do that." So first, it's important to realize that you are depressed and let off some steam.

Talk to Someone

Talk it over with someone, preferably a counselor. Family members eventually get worn out with the topic. Also, they may feel threatened by these losses, so you may hold back some of your discontent. A physician said he would be ruined if he talked to a counselor. His insurance would not cover him anymore if he had mental health counseling. If you worry about such repercussions, try a minister or a wise friend. Another option is to pay for these services yourself and not charge them to your insurance carrier. Some big group practices have a private Employee Assistant Program just for their physicians. The CEO may insist that they go there, but does not know what happens when they do. In many cases, the problems are solved, and that is his or her only concern. You can take advantage of these programs voluntarily.

Separate whether you dread most how the change will affect you or how others will take it. Will your spouse and children make you miserable because you are bringing in less money? How can you talk about it? Is there anything that can be done? Can you cut back on expenses? You might say to family: "This is happening. We have to cut back somewhere." Does everyone give up something or do you decide who gives up what? Often it can't be a democratic family vote. Perhaps you decide a daughter must give up riding lessons or a son golf lessons. A teenager might get an afternoon job to finance some of the extras.

Write about It

You can also write out some of these anxieties. Choose paper and pen you like and write 10 minutes a day, five days a week, without worrying about spelling, grammar, or punctuation. Just start writing and don't stop for 10 minutes, whether you think you have anything to write about or not.

Write about the injustice of all the changes in health care. Lambaste the legal profession, the new managed care structures, ungrateful patients, whoever is causing longer hours and less money. When you do this kind of writing, you may touch on subjects that surprise you and that you wouldn't ever want anyone to see. If that happens, tear up the paper it is written on. You don't have to keep it to have the process benefit you. As Peter Elbow says, "Garbage in your head will poison you, but garbage on paper can safely be put in the wastepaper basket."[2]

Complaining, moaning, groaning, and righteous indignation are useful for a time--they are a natural and essential first step when a loss occurs, but they are not a place to dwell too long. Soon, people will get on with things, and you'll be left behind if you don't find a way to deal with and incorporate some of the changes into your life.

What can help you move to this next stage?

Relaxation

Dr. Herbert Benson's relaxation response has gotten a fair amount of publicity in recent years.[3] You may have heard it often enough that you react--oh, that again. It's easy enough to think about relaxation, conclude that you know how to do that, and shrug it off as not important; it couldn't possibly have all the benefits it is touted to have. It is extremely important, but many high-powered people have never experienced it. They plan events and move just as fast and compulsively on vacations as they do in their offices.

I'm talking about more than just vacation relaxation anyway. I want you to stop at least once a day and slow your body and mind down to the point that you are limp and mentally drift into unawareness. The most effective method for me is a relaxation tape that soothingly instructs me to tighten each group of muscles and then release them while breathing deeply and slowly. Some people have effective results with meditation or prayer. It does not matter what technique you use as long as you reach the desired state. You slow the mind and body down to the alpha state.[4] It is impossible to be relaxed and anxious at the same time--the two conditions simply cannot exist simultaneously. Doing the relaxation exercise at least once a day not only improves your mental outlook, but also increases your energy, and may even heal your body.

If this seems especially difficult for you, consider whether you might cut back on caffeine. Even over-the-counter decongestants can rev up your mind, interfere with your ability to relax, and make you depressed.

Talk Positively to Yourself

After you learn to relax, start talking positively to yourself at the end of the relaxation time. Try saying, "I will be all right in the new structure," instead of "I'm going to be out on the street, no money, and everyone bossing me around like a prison inmate." Other statements you might try: "I enjoy being free of worry, fear, and anxiety." "I enjoy every day." Ideally, you want to come up with your own positive statements that fit your situation.

In the beginning, say the positive statements to yourself right after the relaxation exercise. Then extend the time you say the same sentences to yourself throughout the day. Our minds work much like the scan buttons on modern car radios. We blip from one thought to another at an amazing speed, and, for a lot of people, much of what they are saying to themselves is negative, has a doomsday theme to it.

"You participate in a daily dialogue--everything you say to yourself and others during the day, all thoughts both deliberate and spontaneous. Your dialogue is important because it is the way you give instructions to yourself--both to your body and to your mind. It is important to change your dialogue to yourself and others from negative, self-destructive things to positive self-enhancing things.

"You are what you tell yourself you are. You feel what you tell yourself you to feel. You become what you tell yourself. It doesn't matter whether or not you actually believe the new dialogue. In fact, it will not be true in the beginning, and it will feel strange and uncomfortable. The essence of change is to do something enough until it becomes true."[5]

If you say positive statements to yourself at the end of your relaxation tape or meditation, your unconscious more easily accepts the idea.

Try to Rethink the Situation

Is there any way you could be happy with some of the changes? Can you change your reaction to the new trend of collecting outcomes data? Instead of thinking someone is trying to catch you doing something wrong, can you be glad to know how others are successfully treating patients. Instead of saying to yourself: "They are trying to make me change the way I practice medicine. Only I know what is best for my patients in a given situation," could you adopt an attitude of curiosity. "So six out of ten of the internists use this cheaper drug to treat pneumonia. I didn't know what the others were doing. It's nice to know and not be doing everything in a vacuum. I think I'll give it a try and monitor the patient's responses closely. I like knowing what others are doing."

Dr. George Linney says, "Sometimes if I am going round and round in my head on the negative stuff, I can do certain activities that will be upbeat and happy, and then I come back to the problem and do something besides go round and round. If I have a difficult confrontation coming up, I might listen to classical music in brass. It is very powerful, trumpets and trombones, all those horns. It's different from violin and string music. It makes me feel powerful and in control. I also listen to other tapes--country and western, rock and roll, religious, or an inspirational speaker to help me change my mind set."[6]

Can you still get pleasure from helping some people get well? Dr. Raymond Fernandez says, "We have to keep remembering why we went into medicine in the first place."[7]

Can you try to shift your value focus? Be happy about good health, a chance to work, satisfying relationships. If you have to take fewer vacations, enjoy the ones you take more. Make the time count. Don't take work distractions with you. Talk to and listen to your loved ones. Do something fun that you have never allowed yourself to do before.

Viktor Frankl, who survived four concentration camps, says that "everything can be taken from a man but one thing: the last of the human freedoms--to choose one's attitude in any given set of circumstances, to choose one's own way."[8]

Take Action to Control What You Can

An old proverb says, Change is the mother of twins--fear and excitement. Can you think of any way to be excited about some of the changes? When there is so much you can't control, try to find something you can control. I know a Florida physician who has been part of a team that is planning a state HMO. He said if you had asked him six months ago if he would be involved in such a project he would have said no. Some physicians are helping with the formation of the many physician-hospital organizations that are jockeying to get in place. "You might volunteer to work with your hospital, group practice, or IPA on outcomes monitoring projects."[6]

"Do something appropriate and constructive and do it every day. Take some action that will move you forward."[9] Exert what control you can and then try to be flexible, not wasting too much energy resisting what's inevitable. "Life ultimately means taking the responsibility to find the right answer to its problems and to fulfill the tasks which it constantly sets for each individual."[10]

References

[1.] Wallen, E. "Job Pressures Seen Fueling Rise in Doctors' Stress Levels." Physicians Financial News Oct 15, 1993, pp. 15-16. [2.] Elbow, P. Writing Without Teachers. London: Oxford University Press, 1973, p. 8. [3.] Dwyer, C. The Shifting Sources of Power and Influence. Tampa, Fla.: American College of Physician Executives, 1991, p. 53. [4.] Gillett, R. Change Your Mind. Change Your World. New York, N.Y.: Simon & Schuster, 1992, p. 142. [5.] Covington, F., and Seagrave, A. CHAANGE Handbook. Charlotte, N.C.: CHAANGE, 1986, p. 9. [6.] George E. Linney Jr., MD, FACPE, Health Care Consultants. Personal communication, Nov. 1993. [7.] C. Raymond Fernandez, MD, FACPE, Medical Director, Nalle Clinic, Charlotte, N.C. Personal communication, Aug. 25, 1993. [8.] Frankl, V. Man's Search for Meaning. New York, N.Y.: Washington Square Press, 1985, p. 86. [9.] Alexander, J. Dare to Change. New York, N.Y.: Signet Books, New American Library, 1984, p. 99. [10.] Frankl, V. Op. cit., p. 98.