The temper-tantruming physician.

ANGRY PHYSICIANS CREATE PROBLEMS--FOR THE people they treat and work with, for their administrators, and for their loved ones. Addressing negative emotions is one of the most prevalent organizational and personal challenges facing physician leaders. "The flow of negative emotions that all too often permeate today's organizations: anger, depression, anxiety--in the guise of low morale--stunt organizational effectiveness if not contained and managed effectively."[1] On a personal level, the struggle may he even more toxic. "One of the most common stresses of physician leaders is the difficulty in dealing with an abusive, arrogant, technically superb, but interpersonally unskilled physician."[2] Solving this problem starts with taking an honest look at the factors and processes that shape physicians' coping patterns. Learning effective emotional management skills is underscored by a simple fact: Emotions are contagious.

Are physicians trained to cope well?

It is clear that physicians are facing extraordinary stressors that are diminishing their overall ability to function. Changes in the health care system have stripped physicians of much wanted control in their work settings[3] at the same time that their personal lives are being revamped by changes in family structures and values. Fully 70 percent of today's professionals indicate that they are stressed by the struggle to balance home and work responsibilities,[4] and between 30 and 50 percent of male physicians wish to change careers in hopes of creating a more comfortable work/family balance.[5] Worldwide, studies indicate that between 30 and 50 percent of physicians report anxiety, sleeplessness, or depression in reaction to personal problems, statistics that are significantly higher than in other professions.[6]

Two factors predispose physicians to have difficulty managing their emotions. First, in the process of medical education and training, most physicians perfect a special, depersonalized type of relating with people. The result may be a middle-aged man or woman, who has well-honed role-related abilities but who lacks the skills for dealing with interpersonal relationship stresses.[7,8] Second, the high-pressure, time-urgent environments that typify virtually all medical training or practice settings compel physicians to develop Type A coping styles.[6,9]

The Type A behavior pattern (TYABP) refers to an aggressive coping mode that incorporates some combination of workaholism, cynicism, hostility, polyphasia (doing and thinking more than one thing at a time), time urgency, competitiveness, and an excessive need for controlling outcomes in interpersonal relations.[10] No one evidences all of these characteristics, yet it has been estimated that approximately 70 percent of people living in urban populations and only a slightly smaller percentage of those living in rural populations evidence at least one pronounced Type A coping habit." This proves especially true for physicians: Cross-cultural research suggests that, compared to the general population physicians show elevated scores on TYABP measures, and that women physicians are at particular risk of developing TYABP.[12]

Physicians, Type A behavior, and relationships

While TYABP may be an adaptive mode of meeting many of the challenges at work, unchecked it wreaks havoc in the physician's interpersonal realm.[5] A broad-based literature search uncovered five observations that hold important implications for understanding how Type A's think, behave, react, and function in relationships.[6,13]

1. Type A's tend to selectively perceive others as challenging them.

2. Despite their often gruff and insensitive behavior, Type A's tend to be hypersensitive to criticism.

3. Type A's tend to react competitively in small groups, especially when dealing with other people who show TYABP.

4. If open conflict with another occurs the Type A tends to show an initial flurry of reactivity as he or she tries to regain control of the relationship.

5. If control is not regained by this initial flurry of action, the Type A then shuts down by withdrawing from further interactions.

6. When stressed by aspects of life that are out of their control, some Type A's evidence exaggerated stress reactivity and impaired calming functions.

These findings hold profound implications in light of an additional fact: Teams are shaped by the most consistent behavioral and emotional patterns shown by the members. This is due to the phenomenon of emotional contagion: "The tendency to 'catch' (experience/express) another person's emotions--his or her emotional appraisals, subjective feelings, expressions, patterned physiological processes (e.g., breathing rate, eye contact, gestures), and behavior."[1] Mismanagement of your own emotional and behavioral reactions--especially when dealing with another person who is doing the same--simply leads to escalating inappropriate behavior.

In this sense, many physicians develop coping habits that lead to a negative emotional contagion: As their Type A behavior pattern and its destructive interpersonal sequelae fill work and home settings, their negative emotions spread, creating problems that they are then forced to deal with. Put another way, the very ways that physicians learn to survive at work can work against their ability to appropriately manage relationships.[6]

Changing: The effective emotional management model

Many physicians--and many Type A's--enjoy thriving professional and personal lives 6 What distinguishes these people from those who crash and burn in response to similar stressors? Our search for answers to this question culminated in the Effective Emotional Management (EEM) model of stress hardiness.[6,14] In large part, this model was derived from our study of approximately 450 physicians and their loved ones and from the stress hardiness literature.[6] EEM can serve as a backdrop for structuring personal and professional efforts to manage the angry physician.

In simple terms, EEM proposes that you will be better able to cope with the demands of daily living if you attend to two broad factors. First, you need to learn to disrupt problematic coping progressions by making more adaptive cognitive, behavioral, physiological, or interpersonal choices. Second, you should work to create and maintain supportive environments and social networks by attending to the situations, processes, and relationships that form the "territory" of your life.

Setting the context for change

Anger management hinges on controlling your baseline levels of stress and your coping style. The EEM strategies outlined below are designed for this purpose. But before employing specific strategies, it is important to set a context for anger management.

The key to managing anger is not to wait for it to feel different; make it different by changing your behavior. Here, as in learning any new behavioral or emotional pattern, you must endure the awkwardness of changing. One way to conceptualize the change process is that you must first clarify your attitude about how you want to be, then commit yourself to behavior that expresses that way of being. With enough accumulated behavioral practice, the new pattern will eventually become comfortable on an emotional level. If you can imagine how you would like to react, you can "pretend" being that way; and if you "pretend" it long enough, you will become it.

Managing anger does not mean obliterating it from your emotional repertoire; it means developing a style of reacting to your own anger that is adaptive. Even if you have difficulty controlling your emotions, you can learn to control your cognitions and behaviors when angry. Anger management efforts should address three distinct factors:[20]

Anger--an unpleasant emotion ranging from irritation to rage

Aggression--overt behavior such as attacking, destructive, or hurtful actions

Hostility--an attitude of distrust of others, with a wish to inflict harm on them.

Managing yourself while managing others

A number of specific strategies for self-management are outlined in Table 1.[14] In addition, physician leaders can enhance their personal and professional effectiveness by following six guidelines that stem from the EEM model.[5]

TABLE 1 Controlling anger
  * Keep an anger journal
  * Lower baseline levels of tension
  * Use alternative stress-reduction strategies
  * Break-up adversive chain reactions
  * Use imagery and response rehearsal
  * Use effective interpersonal tools
  * Practice empathy
  * Use time out
  * Develop a list of coping statements that help in refraining
anger-generating thinking patterns.

--Adapted from: Sotile, W.M.: Physical Interventions for Cardiopulmonary Patients: A Guide for Health Professionals. Champaign, IL: Human Kinetics, 1996.

1. Learn to discriminate. In EEM, as in practicing medicine, effective treatment is dependent upon accurate diagnosis. Different emotions require different courses of corrective action. Anger control hinges on increased emotional awareness. Learn to discriminate when you are tense, simply rushed, or downright angry.

2. Be honest about your TYABP and its effects on those around you. As a physician leader, you have much to do with setting the tone of your organization. Take responsibility for the effects of your own coping and communication habits. "Start by listening to yourself as you deal with (others). Ask for feedback from them regarding your way of relating to them. You might even tape record an evening's conversation with your family, and then listen to the tape with an ear toward noticing your own communication style."[6] Through role playing or with the aid of audiotaped or video-taped interactions, learn to attend to various aspects of your communication style such as what you say (i.e., words, nonverbal sounds) and how you say it (i.e., voice quality, tone, and volume, as well as body movements, facial expressions, and gestures). Notice yourself. What does your style of communicating generate? Tension? Defensiveness? Cooperation? Comfort? He particularly cautious about the relationship effects of the various Type A factors outlined in Table 2.

TABLE 2 Relationship effects of mismanaged
Type A behavior pattern

Time urgency       Impairs connection with others
Polyphasia         Yields poor communication and empathy
Impatience         Increase stress on others
Perfectionism      Increase criticism of others and lowers
                   levels of positively reinforcing interactions
                   with others
Irritation/        Increases alienation and wounding of others
Hostility
Controlling        Others stop self-disclosing or avoid
                   interacting with the Type A
Competitiveness    Others avoid the Type A in order to escape
                   being "put down"

Adapted from: Sotile W.M. & Sotile M.O.: The Medical Marriage: A Couple's Survival Guide, New York: Birch Lane Press, 1996.

3. Respect your physiology. Don't forget the basics in managing your own stress reactions. Beware of caffeine, nicotine, and simple sugars--stimulants that can magnify an already-existing supercharged nervous system. Avoid falling prey to the Type A "rollerball:" alternating stimulants and sedatives in order to get through yet another grueling day. Instead, try these stress-lowering strategies:

Regularly engage in aerobic exercise; it has been found to lessen the physiological hyper-reactivity many Type As experience when facing stress.[21]

Practice responding in non-Type A ways by countering hurry sickness. When there is no pressing need to hurry, force yourself to drive slowly while listening to relaxing music. Stand in the longest line at the check-out counter. Create islands of time during which you do one thing at a time. Practice doing nothing for 15 minute stints of time--simply in order to get more familiar with slowing your pace.[22] The point of these exercises is to increase your coping flexibility. By becoming familiar with a more relaxed, evenly-paced way of reacting, you gain important coping leverage: You develop the power to choose how you will react and when you will react.

Get out of your head and into your senses. If you allow yourself to react naturally, you will probably drift into thinking in ways that take you out of awareness of the moment and into Type A reactivity. Instead, practice becoming aware of what is happening right now. Notice the sights, sounds, smells, and physiological sensations of the moment. Practice heightened sensory awareness while alone and when dealing with others in conversations at work and home.

4. Manage your attitude. A crucial component of EEM is embracing the three C's of stress hardiness suggested in the seminal research of Suzanne Kobasa and colleagues.[23] Stress hardiness is enhanced if you are able to view coping with a given stressor as a challenge, commit yourself to facing that challenge, and know what needs to be learned in order to gain a reasonable sense of control over the coping process.

Whether dealing with professional or personal stresses, ask yourself and your "teammates" at home and work: "How are we defining this stressor?" For example, do you see what you are facing as being a punishment, a relief, an opportunity, a beginning, an ending, a warning, or a tragedy? It is important to practice empathy and compassion when feeling hostile. Practice recalling calming phrases when anger arises. You might remind yourself: "This problem is not the most important thing in my life;" or "This person is not perfect, and neither am I."

You can help manage your outlook by using reframing and relabeling techniques such as the following:[6]

* Learn to use humor.

* View setbacks as learning experiences, changes as challenges, and stressful times as necessary steps toward desired goals.

* Remember that uncertainty is often due to the nature of medical science, not to your personal limitations.

Special care should be taken to manage the attitudes that fuel TYABP, as outlined in Table 3.[24] Recognizing and countering Type A assumptions with realistic appraisals is a crucial step in controlling the effect that your coping style will have on your own and others' well-being.

TABLE 3 Type A beliefs and behaviors

Believing that...

* I must constantly prove myself

* My sense of well-being is always in jeopardy

* Others can take away my self-worth

* I am not as talented as others

* Good may not prevail in the world

* All resources are scarce

The Type A acts...

* As if life an endless struggle

* Hostile

* Competitive and jealous and critical of self and others

* As if he or she must always try harder than others

* Suspicious of the intentions of others

* Urgently competitive

(*) Recognizing and countering such assumptions with realistic appraisals is a crucial step in controlling the effect that your coping style will have on your own and others' well-being.

From: Heart Illness and Intimacy: How Caring Relationships Aid Recovery, by W. Sotile. Baltimore, MD: John Hopkins University Press, 1992, p. 179.

5. Curb workaholism. Workaholism drains coping energy, increases irritability, and generally ruins the quality of your life, starting with important relationships. Are you a workaholic? Guidelines for answering this question are presented in Table 4.[25]

TABLE 4 Sings of work addiction

* Constant hurrying

* Relentless need to stay busy

* Struggling with an excessive need to control

* Perfectionism

* Difficulty with relationships

* Regularly engaging in work binges: work highs lead to work hangover, withdrawal, anxiety, and depression. In advanced stages, work binges are concealed to avoid disapproval

* Difficulty relaxing and having fun

* Brownouts due to exhaustion and mental preoccupation with planning and work

* Impatience and irritability

* Feeling of self-inadequacy unless working

* Self-neglect in deference to the need to keep working

From: Sotile WM & Sotile MO: The medical Marriage: A Couple's Survival Guide. New York: Birch Lane Press, 1996

If you do not evidence workaholic behavior, you are indeed an exceptional physician. The average male physician still works between 68 and 80 hours per week in his career pursuits,[25] with 38 percent reporting that they work more than 80 hours per week.[2] While married female physicians work 90 percent as much as their male colleagues,[2] they still typically continue to assume full responsibility for doing or overseeing the work involved in managing their homes.[29] The result? They endure 86- to 107-hour work weeks.[30]

Be honest if you are stuck in workaholic behavior. A literature search suggests that physicians experience significantly more difficulty than other professionals in winding down after a regular workday, in controlling hours spent working, and in finding ways to switch channels from a task-orientated focus to social activities, or to interacting with family.[31] In fact, only approximately 10 percent of physicians report that they regularly take time off from work to relax or to take vacations exclusively for vacation's sake.[31]

Use your resources to save time and energy, and practice anti-workaholic behaviors, such as:

* Pause throughout the day, even if only for a moment, before addressing your next task.

* Protect time to be with loved ones.

* Take many, mini vacations.

* Set limits on the extent to which you are available for extracurricular activities that take you out of your family or preempt your time for engaging in personal nurturing.

6. Manage relationships Managing anger requires practicing positive relationship skills like listening and reflecting what you hear from others; being supportive of others; showing trust in selected people by sharing your feelings with them; and talking with others about your personal philosophies for creating balance in your life, as well as soliciting their ideas.

Summary

A key to remaining stress-hardy, as a physician leader, is managing yourself. This means different things in various contexts: "Associate with people who soothe you, not with those who stir your competitive edge. Fill your time with activities that comfortably stimulate you, not with ones that fuel your aggressive and hostile reactions. Run interference for yourself by learning to anticipate which situations and people are likely to push your TYABP buttons, and, when possible, avoid them. If you cannot avoid such situations or people, carry into the difficult circumstance a reminder to relax, notice your own inner thinking or feeling, and control your behavior."6 Geared with the stress-hardiness that results from such personal management, you well be better able to control anger: your own, and that of your colleagues.

References

[1.] Weisinger, H. Anger at Work New York: William Morrow and Co, 1995, p. 54.

[2.] Pfifferling, J.H. Ounces of Malpractice Prevention. Physician Executive. 20(2):36-38, 1994.

[3.] Linney, BJ. Surviving in a World of Change. Physician Executive 20(2):39-41, February, 1994.

[4.] Gibbs, N.R. Bringing Up Father. Time, June 28, 1993:55-56.

[5.] Dayton, M. Survey:One in Five Suffering From Stress. Lawyers Monthly 3(March):15, 1991.

[6.] Sotile W.M., and Sotile M.O. The Medical Marriage A Couple's Survival Guide. New York: Birch Lane Press, 1996.

[7.] Marcus I.M. Harmony vs. Discord in Marriage: A View of Physicians' Marriages. J of Louisiana State Med Soc 1980;132(11):173-178.

[8.] Gabbard GO, Menninger RW, & Coyne L: Sources of Conflict in the Medical Marriage. American Journal of Psychiatry 1987;144:267272.

[9.] Lewis JM, Barnhart FD, Howard BL, Carson DI, & Nace EP: Work Stress in the Lives of Physicians. The Journal of Texas Medicine 1993;89(2):62-67.

[10.] Friedman, M. and Rosenman, R.H. Type A Behavior and Your Heart. New York: Knopf, 1974.

[11.] Thoresen, C.E., and Low, K.G. Women and Type A Behavior Pattern:Review and Commentary. In MJ. Strube, (Ed.), Journal of Social Behavior and Personality, (Special issue), 5(1):117-133, 1990.

[12.] Sterndorff B, Smith DF: Normal Values for Type A Behavior Patterns in Danish Men and Women and in Potential High-Risk Groups. Scandinavian Journal of Psychology 1990;31: 49-54.

[13.] Sotile, W.M., Sotile, M.O., Ewen, G.S., and Sotile, LJ. Marriage and Family Factors Relevant to Effective Cardiac Rehabilitation: A Review of Risk Factor Literature. Sports Medicine. Training and Rehabilitation 4:115-128, 1993.

[14.] Sotile, W M. Psychosocial Interventions for Cardiopulmonary Patients A Guide for Health Professionals. Champaign, IL: Human Kinetics. 1996.

[15.] Houseknecht, S.K. & Macke, A.S. Combining Marriage and Career: The Marital Adjustment and Professional Women. Journal of Marriage and the Family 1981;43:651-666.

[16.] McCue, J.D. & Sachs, C.L. A Stress Management Workshop Improves Residents Coping Skills. Journal of Internal Medicine 1991;151: 2273-2277.

[17.] Elliot, F.R. Professional and Family Conflicts in Hospital Medicine. Social Science and Medicine 1979;13A:57-64.

[18.] Quill, D.E., Williamson, P.R. Healthy Approaches to Physician Stress. Arch Intern Med 1990;150: 1857-1861.

[19.] Simpson, L.A. & Grant, L. Sources and Magnitude of Job Stress Among Physicians. Journal of Behavioral Medicine 1991;14(1):27-42.

[20.] Smith, T.W. Hostility and Health: Current Status of a Psychosomatic Hypothesis. Health Psychology 11(3):139-150,

[21.] Blumenthal, J.A., Emery, C.F., Walsh, M.A., Cox, D.R., Kuhn, C.M., Williams, R.B., & Williams, R.S. Exercise Training in Healthy Type A Middle-Aged Men: Effects on Behavioral Cardiovascular Responses. Psychosomatic Medicine 50:418-433, 1988.

[22.] Freidman, M. and Ulmer, D. Treating Type A Behavior and Your Heart. New York: Alfred A. Knopf, 1984.

[23.] Kobasa, S.C.O., Maddi, S.R., Puccetti, M.C., & Zola, M.A. Effectiveness of Hardiness, Exercise and Social Support as Resources Against Illness. Journal of Psychosomatic Research, 29:525,1985.

[24.] Sotile, W.M. Heart Illness and Intimacy How Caring Relationships Aid Recovery. Baltimore, MD: Johns Hopkins University Press, 1992.

[25.] Robinson, B.E. Work Addiction: Hidden Legacies of Adult Children. Deerfield Beach, Florida: Health Communications, 1989.

[26.] Fabri, PJ., McDaniel, M.D., Gaskill, H.V., Garison, R.N., et al. Great expectations: Stress and the Medical Family. J of Surgical Research 1989;47(5):379-382.

[27.] Freiman, M.P and Marder, W.D. Changes in the Hours Worked by Physicians, 1970-1980. American Journal of Public Health 74:1348-1352, 1984.

[28.] Weisman, C.S. & Teitelbaum, M.A. The Work-Family Role System and Physician Productivity. Journal of Health and Social Behavior 1987;28: 247-257.

[29.] Heins, M., Smock, S., Jacobs, J., et al: Productivity of Women Physicians. JAMA 1976; (236)1961-1964.

[30.] Greenglass, E.R. Type A Behavior, Career Aspirations, and Role Conflict in Professional Women." In: MJ. Strube (Ed.), Type A Behavior (Special Issue). Journal of Social Behavior and Personality 5(1): 307-322, 1990.

[31.] Krakowski, AJ. Stress and the Practice of Medicine: The Myth and the Reality. Journal of Psychosom Res 1982; 26(1) 91-98.

Wayne M. Sotile, PhD, and Mary Owen Sotile, MA, Co-Direct Sotile Psychological Associates in Winston-Salem, North Carolina, and travel internationally as consultants to medical groups regarding stress and conflict management. The Sotiles can be reached at 910/765-3032. Their new book, The Medical Marriage: A Couple's Survival Guide was published this year.