Understanding the stresses and strains of being a doctor

The educational mission statement of Brown Medical School in the United States states, in part, “We intend that our students follow in the altruistic tradition of medicine, placing the welfare of their patients and society above self-interest.”1 In the context of medical practice today, is this tradition adversely affecting doctors and their ability to practise?

Many studies have documented stress2 and higher than expected rates of psychiatric morbidity in doctors and medical students. 3,4 Doctors are particularly subject to substance misuse,3,5 and one study found suicide rates in male doctors to be about double those expected. 6 The impact of this morbidity on doctors and those around them is profound and serious.

However, most of us enjoy reasonably good health. Our physical health is comparable with that of the general population,7 and our overall mortality rate is low. 6 Members of our profession are comparatively well off, resource-rich, financially secure and reasonably well regarded in the community. Doctors are arguably as comfortable and content as our contemporary value system permits.

Nevertheless, surveys continue to suggest that, as a profession, we feel stressed. As a member of a Medical Board and a psychiatrist who cares almost exclusively for doctors, I have wondered: are we suffering because of the nature of our work, or is it more to do with the character of doctors? And what should we be doing about it?

Work stress is defined by the discipline of occupational health psychology, which is founded on a core set of notions that help us to think more clearly about the nature of stress at work (Box 1). Karasek’s model of “demand–control imbalance”8 or “job strain” states that jobs are stressful if they combine high demands with no power or authority to alter the situation. In this model “perceived low control” is considered the major source of work stress and a predictor of poor physical (including cardiovascular) and mental health outcomes. 11 Subsequently, Siegrist showed that “effort–reward imbalance” is also a powerful source of work-related ill health. 9 Finally, the concept of “support” was added to capture the notion of having the right tools for the job and supportive relationships in the workplace. 10

I believe that these concepts resonate with doctors’ current concerns regarding their work. Surveys among doctors identify similar subjective issues as sources of work stress (Box 2). 12,13 Doctors consistently experience high intensity of work, conflicting time demands, and heavy professional responsibility, often in systems where physical and social resources are deficient, and there is the ever-present threat of medicolegal action. Further, doctors often have limited power to alter the conditions under which they work. Indeed, most of the survey responses listed in Box 2 relate to lack of control or lack of reward in the face of unrelenting effort. For example, the threat of litigation, which emerged as the number one source of stress for general practitioners in the study by Schattner and Coman,13 illustrates perfectly the sense of powerlessness and negative reward felt by doctors.

There is general agreement in the medical literature that some degree of obsessionality of personality is extremely common in doctors. 14-16 This quality, combined with high intelligence, generally results in conscientiousness and commitment, which are considerable assets in any endeavour. However, in doctors, it is also a source of vulnerability. An excessive obsessional trait results in dysfunctional perfectionism, inflexibility, overcommitment to work, isolation of affect, dogged persistence and an inability to relax. These overly obsessional individuals have an intense perceived need to control their environment.

Applying psychoanalytic theory, Johnson has looked at doctors’ personalities and suggested that a subset of doctors at least is especially vulnerable to a poor sense of self and low self-esteem. 17 This may result from “childhood experiences of parental impotence and emotional neglect”. Attempts at reparation by the individual may lead to “dependence on patients, emotional detachment and denial of personal vulnerability”. 17 This proneness to dependency also commonly affects impaired doctors.

If dependent traits dominate, then a doctor will be too prone to appease patients, including unreasonably demanding patients, and unable to prioritise demands, particularly those of family, and the need for recreation. This type of doctor may enter a cycle of increasingly using patients as the primary source of self-affirmation and avoiding deteriorating relationships at home. A doctor in this situation becomes at risk of boundary violation (see Galletly, page 380).

It has been said that the major contributor to work stress is disposition,18 rather than the nature of the work — how we experience work depends largely on our interpretation of it through the lens of our temperament. However, I would argue that the work of doctors is uniquely stressful, and it is reasonable to posit a model of “mismatch” between the nature of the job and doctors’ personalities.

When demands are excessive and loss of control threatens a doctor who by reason of temperament needs to be in control, the scene is set for a bad outcome. Likewise at risk is a doctor whose disproportionate need for self-affirmation is not met. Commonly, the initial response is to absorb the demand and work harder, and as long as busy periods are moderated by quieter periods this strategy may be successful. But, if demands continue to rise and substantive intentional adjustments are not made, then, in market-speak, a “correction” will inevitably occur. This often takes the form of “burnout”, but sometimes it is a physical health scare that precipitates a review. And, if the warnings are still not recognised, then formal psychiatric decompensation is almost inevitable.

Stress results in strain, manifest as chronic arousal. This is not simple wakefulness, but persistent heightened mental and physical alertness, and it is exhausting. Research shows that doctors are chronically aroused. 19 Burnout is often defined as emotional and physical exhaustion, resulting in poor self-image, negative attitude to work and a drop in personal involvement. 20 Another model that accords particularly well with models of occupational health psychology is that of Meier,21 who describes burnout as “a state in which individuals expect little reward and considerable punishment from work because of a lack of valued reinforcement, controllable outcomes or personal competence.”

This is hardly earth-shattering! So, why don’t we do it? What are the barriers to taking our own advice? Much has been written about this,22 but an obvious answer is that we don’t want to — we actually like to be busy, and even to be stressed. This may be a benign reaction — intelligent and conscientious individuals with a good deal to contribute do gain intrinsic rewards from being productive and effective. Indeed, Karasek calls this “active work”. 8

On the other hand, work may be more comfortable than home life or a holiday and be used, as mentioned earlier, as a way of avoiding these personal aspects of life. Moreover, the serious work of a doctor is difficult for a spouse to repudiate. As family life deteriorates, avoidance grows, stress levels peak and depression and even suicide may become real prospects.

The self-employed doctor can more easily make changes. Perhaps the single most powerful and obvious personal intervention is to change the intensity of demand (ie, to confront and resolve time pressure, conflicting demands and workload). Paradoxically, relinquishing control of the appointment diary to a pragmatic secretary is an example of a simple but effective personal strategy. (Delegation of control is what an obsessional person finds so difficult.) Such a strategy deals with the myth of doctors’ indispensability, and over time can produce behavioural change in a doctor as he or she experiences the real benefits of reduced intensity, slower pace and genuine recreation.

Those who manage health systems that employ doctors need to recognise that, as well as realistic workloads, there is a need to

• provide opportunities for doctors to participate in administrative decision-making,

• respect their reasonable need for autonomy and control, and

• nurture their sense of being valued.

A recent survey of 608 physicians in the United States found that a sense of control over the practice environment was the most important predictor of psychological wellbeing, satisfaction and professional commitment. 23 This sense of control included the “opportunity to participate in decision making, to work autonomously and to dictate the work schedule”. If healthcare organisations want healthy, happy doctors, they need to engage them in the design and delivery of healthcare.

Generally, this has been well managed in Australia, but there has been a preparedness to condone the obsessional doctor’s “workaholism” by sometimes applauding it as conscientiousness (“going the extra mile”), when, in fact, it may be pathological. This may ultimately be detrimental for the doctor, and for other staff who may be affected by collateral emotional damage, not to mention the potential effect on patient care. Institutions have a responsibility to monitor and moderate the excessive commitment of some doctors, and this may need to go as far as mandating leave in an effort to preclude a breakdown.

Next, we need to be able to recognise the red flags indicating impairment (Box 3). These are essentially signs of decompensation and failure to cope, and are often ignored until “too late”. Medical boards, health complaints authorities and hospital administrations are alert to the fact that complaints about a doctor may be an indicator of impairment. Obviously, it is preferable to respond to impairment or distress before it comes to attention through complaint channels.

Finally, we need to be alert to early but overt signs and symptoms of substance misuse and formal psychiatric illness.

To effectively respond to a colleague in need, the profession must put in place well-defined programs and pathways of response. Some excellent work in this regard has been done in Australia, a good example being the strategies developed by the Doctors’ Mental Health Implementation Committee of the New South Wales Medical Board24 (see Wilhelm and Reid, page 372). This program shows the need for a systematic approach if we are to expedite effective responses. We need to provide pathways to increase the likelihood of concerned doctors or others taking action. Hospital administrations, medical defence organisations, the Colleges and other relevant organisations must have clear pathways of response that are promulgated and rehearsed by appropriate personnel (“rehearsed” in this context means discussed, learned and even practised — for example, in role-play).

The essential elements of the response pathway must be in place. First, colleagues need to know who to contact to share their concern and have a preliminary discussion about the problem. Identified contacts must have a clear sense of what needs to happen in response to a concern being raised, so that they can give advice, suggest an intervention, or, when appropriate, implement the intervention. Further, they need ready access to identified clinicians, usually psychiatrists, who can take responsibility for referred cases.

Doctors’ Health Advisory Services already provide invaluable assistance in this regard, but this system is voluntary and best reserved for those who refer themselves or for referrers who are unaware of alternatives. The existence of this safety net does not diminish the need for a concerted effort to develop effective, institutionally based systems of response.