A Stress-Reduction Guide That Works

You’ve got a waiting room full of patients, and you’re running behind. You just received notice of rising malpractice premiums, and yet your reimbursement rates continue to drop. And you haven’t been home in time for dinner in what feels like weeks.

You’re feeling stressed, exhausted, burned out, frazzled, and frustrated.

Sound familiar?

This kind of chronic stress - that is, the day-to-day shuffle that is your job - can’t be cured with a warm bubble bath and a cup of hot tea. It’ll take more than a few deep breaths to ease your mind and regain control of your practice and your life.

Ignoring the signs of stress or simply brushing off the burden as an occupational hazard can only make it worse, and could lead to unhappiness, depression, or even a clinical mistake. So before you let yourself be crushed by a stressor snowball, it’s time to find a real, permanent fix. But don’t toss out the rubber ducky quite yet - there’s a place for stress-relieving soak time, too.

Acknowledge your stress

Physicians typically aren’t taught to acknowledge their stress, and instead tend to deny it, says Barry Bub, a physician and director of Advanced Physician Awareness Training, which provides career counseling and workshops for physicians dealing with trauma. “We are desensitized, because [stress is] an ongoing thing we have had our entire professional careers,” he says.

Bub makes a distinction between stress and trauma, the latter referring to specific moments, such as making a medical error or receiving a court summons, which can be particularly debilitating.

“When stress is overwhelming, it becomes toxic and unhealthy. When it’s beyond that, it’s trauma,” he says. “Medical practice equals chronic stress with moments of trauma.”

Although it may seem commonplace for most docs, Bub points out that it is not, in fact, normal to be sleep deprived, constantly fearful of mistakes, or perpetually short on time. It’s no wonder skyrocketing burnout and higher-than-average suicide rates plague the profession.

The long-held beliefs of the profession, passed down during medical school and proliferated among practices, are part of the problem, Bub says. Starting with the grueling hours during residency, the culture rewards those who can handle the long hours and being on call for days at a time, not to mention always being available with the right answers for patients. The image of the superhuman physician is glorified - to the detriment of the profession.

Take for example the whole notion of time. Rather than cultivating best practices that will save time in the long run - such as listening to a patient - physicians tend to rush through visits so they can see more patients. Time spent building a connection with the patient could lead to a more engaged (and thus, potentially healthier) patient - and certainly a more fulfilled physician, Bub says.

Physicians have fallen into the trap of thinking that time spent listening and building relationships is not productive time, he says. They have to break out of this cycle, perpetuated by the profession, to truly set out on the path toward less stress.

Wayne Sotile, a Winston-Salem, N.C.-based consultant and author of “The Resilient Physician,” credits an erosion of physician control and support for the soaring burnout rates and pull-your-hair-out stress physicians are experiencing.

Where there was once was camaraderie, there now tends to be acrimony, Sotile says, as physicians circle the wagons to protect their revenue and patient load. Many doctors are just trying to hang in there, becoming more isolated and disgruntled.

Dissect your stress

One of the first steps to tackling your mounting stress is determining the source - or sources, because it’s probably more than just the fact that you are running behind and can’t find a patient’s chart. It’s time to dig into the layers of frustration in an exercise one consultant calls a “stress biopsy.”

“If we don’t get a comprehensive view of where the stress is coming from, then we are bad clinicians, because we aren’t looking at multiple sources,” says Kernan Manion, a psychiatrist whose own burnout led him to found Work/Life Design, a coaching firm for people in healthcare. Manion’s method evokes the diligence of daily journaling, which can really help uncover the heart of the matter. “We begin to dialogue with ourselves, become more inquisitive and more reflective, and become more observant about what is going on,” he says.

To perform this biopsy, set out a framework for the examination, dividing sources into work (which is again divided into content, process, and environment) and personal (including health, relationships, intellectual life, and financial life). Once your woes are properly categorized, you can weigh the sources as mild, moderate, or major, Manion says.

Is wrangling with the insurance companies your primary stressor? Perhaps you have a teenager at home who is acting out. It could be a greater than average number of difficult patients, or the dismal state of your financial affairs.

Although you can start to dissect your stress on your own with little more than a pen and paper, Manion says the support of a professional can help the process.

With stressors identified, it’s easier to begin to find solutions. You may find that relieving some stressors requires a dramatic shift in your lifestyle, and that building a happier career calls for more than an attitude shift and an exercise routine.

Perhaps you’d prefer to take fewer payers, or work fewer days a week. Maybe it’s time to consider working for a smaller group or for a hospital. This soul-searching exercise can help narrow the scope of your woes, and provide you with the insight and direction you need to make effective changes.

Go beyond stress reduction

For many physicians, stress can be managed by making changes in their daily routine, interactions with others, and taking a different approach to career and personal life. To truly live a less stressful life, Bub says, you can’t just seek to reduce your burden. Bub advises physicians to learn ways to live a life richer in time, meaning, and personal relationships. It may not be easy, but each step can bring you closer to a more balanced life. Here’s how to start:

Build meaningful relationships. Physicians tend to enter the profession as individuals, with little training on how to connect and partner with their peers or how to really communicate with one another, Bub says. Physicians are taught independence and resilience, lest they be seen as less-than-perfect or not tough enough to handle the rigors of the job. The notion that physicians shouldn’t be vulnerable and must remain independent can make a physician feel isolated and frustrated. “Learning how to collaborate with colleagues, employees, and patients can make a huge difference in the amount of stress,” says Bub. “The same situation that can be stressful for an individual can be far less stressful to a group.” Take the time to connect with your colleagues and nurture your personal relationships.

You need to find someone - a friend, colleague, spouse, or therapist - with whom you can discuss your dilemmas and problems, says John-Henry Pfifferling, director of the Center for Professional Well-Being, where he counsels burned-out healthcare professionals. “If you have a good partner or coach, you are no longer fearful of failure and it doesn’t wipe you out as much,” he says.

Be mindful of your purpose. Amid the daily hassles, be sure to reflect on the bright sides, says Sotile. “Meaning is the antidote to burnout,” he says. Avoid being stuck in a quagmire, dwelling on, say, the state of healthcare, and instead find the things that help boost your mood and remind you why you practice medicine in the first place.

“If you hold onto the meaningfulness, the sacredness of what you are doing, interacting with this person right here right now, it’s enormously powerful in helping people stay resilient,” Sotile advises.

Take time to give positive feedback and share. When was the last time you really gave props to a fellow physician? Have you ever been to a meeting where your colleagues sang each other’s praises? “We don’t have the opportunity to thank each other for the work that we do,” says Manion. He suggests practices find an evening or a lunch hour once a month to convene for discussion. Add some structure to it, he says, by making it a discussion group or seminar on a specific topic, such as literature and the healing profession. This will help keep pessimism and kvetching at bay, while creating a welcoming environment for sharing insights and positive feelings about your job and the work your colleagues do.

Just say no. Imagine being presented with an entirely unrealistic request like an additional night of call - and actually declining. Often that’s hard for physicians to do, as they are taught to be pleasers and to live up to high expectations. “They are very poor at saying no,” says Pfifferling.

But physicians should learn when to say no (and that saying no doesn’t make you a lousy doctor or colleague), and when to say yes, based on their abilities, rather than expectations, he says.

“It’s about priorities,” Pfifferling explains. For example, plan for a lighter day after being on call, or take a couple of days off after a busy flu season. Say no to unreasonable requests, such as spending every other night on call or to continuing to treat a particularly difficult patient.

“We have myths out there that are unrealistic of our providers and some of them buy into it,” Pfifferling says, adding that unrealistic expectations can cause emotional turmoil.

Have a contingency plan. Pfifferling asks the questions: What happens if you can no longer take care of patients? Or what if you can’t practice in your community anymore, or keep the practice afloat amid declining reimbursements? If you wait until that worst-case scenario hits, you’ll only wind up more stressed out, fearful, and destined to make unwise decisions, he says. If chronic stress is linked to feeling out of control, doctors have to take the reins and adopt an attitude of survival. “I can’t imagine an executive in the corporate world not having a contingency plan, but I can guarantee most physicians don’t have contingency plans,” he says. Of course, Pfifferling isn’t advising that you obsess over the what-ifs of your future. But physicians, he says, are more likely to stay in a toxic situation if they haven’t conceptualized a potential out, planned for the worst-case scenario, or remained flexible to change.

Let yourself laugh. For Douglas Farrago, a family doctor in Auburn, Maine, humor has always played a prominent role in maintaining a level head. His regular banter with his partner-friends grew into the creation of the Placebo Journal, a monthly publication of funny jokes and stories aimed at letting physicians laugh at themselves. “You can laugh at some of the things you do and realize you are walking in the same shoes as someone else,” Farrago says, adding that commiseration can ease the feelings of isolation. People who can effectively use humor tend to be better at leading, forgiving, and coping, says Sotile. Laughter can also connect you with your patients, and perhaps make an appointment feel less rushed. Of course, use humor wisely (common sense prevails here) and be sure not to offend. When it comes to incorporating humor into your daily routine, Farrago offers this advice: “Self deprecation always works.”

Don’t forget the basics. When a stressful moment strikes, be ready, says Pfifferling. Physicians should find a method for immediately escaping an overwhelming situation. Being able to reframe a moment ensures you don’t just add more fuel to the fire and allow it to get out of control, he says. This could mean taking ten deep breaths or a walk around the block. Manion suggests a mental break for even 15 minutes once a day to refresh your mind and renew your perspective. It may be temporary, but it helps.

Similarly, the daily rituals of taking care of yourself can’t be neglected. They may seem basic, but they are often forgotten: Get plenty of sleep when you can, drink plenty of water, and find time to exercise. Whether it is walking, golf, or yoga, “those fundamentals make a tremendous amount of difference,” Sotile says.

However, regular exercise, “is necessary but not sufficient,” he warns. No amount of Pilates will fully alleviate an overstressed life. You can exercise all you want, he says, but if you don’t work on your relationships, attitudes, and philosophies, you’ll still be miserable.

Sara Michael is an associate editor at Physicians Practice. She can be reached at sara.michael@cmpmedica.com.

This article originally appeared in the February 2010 issue of Physicians Practice.