Anaesthetists

STRESS

IN

ANAESTHETISTS

Published by

The Association of Anaesthetists of Great Britain and Ireland,

9 Bedford Square, London WC1B 3RA, UK.

Telephone [phone]; Fax [phone];

E-mail: [e-mail]

MEMBERS OF THE WORKING PARTY

Dr S M Lyons

Chairman, Immediate Past President

Dr R E Atkinson

Secretary

Professor A R Aitkenhead

Dr A C Brown

Dr M M Burrows

Dr D Dickson

Dr J B Luntley

Group of Anaesthetists in Training

Dr R S Vaughan

Ex Officio

Dr W L M Baird

President

Dr M Morgan

President Elect/Editor

Dr D A Saunders

Honorary Treasurer

Dr D J Wilkinson

Honorary Secretary

Dr P G M Wallace

Assistant Honorary Secretary

Dr A F Naylor

Honorary Membership Secretary

September 1997

© Copyright of the Association of Anaesthetists of Great Britain and Ireland.  No part

of this book may be reproduced without the written permission of the Association of

Anaesthetists.

CONTENTS

SECTION I - SUMMARY............................................................................ 1

SECTION II - INTRODUCTION.................................................................... 3

SECTION III - ASPECTS OF STRESS.......................................................... 5

1. Recognition......................................................................................... 5

2. Causes................................................................................................ 5

3. Sources............................................................................................... 6

SECTION IV - STRESS MANAGEMENT...................................................... 8

1. Control............................................................................................... 8

2. Communication Skills........................................................................... 9

3. Constructive Assertiveness..................................................................... 9

4. Aggression......................................................................................... 10

5. Distorted Thinking............................................................................... 10

6. Time Management............................................................................... 10

SECTION V - STRESS SUPPORT............................................................... 12

1. Personal and Professional...................................................................... 12

2. Mechanisms........................................................................................ 14

3. Conclusion......................................................................................... 23

APPENDIX 1 - VOLUNTARY AGENCIES.................................................... 25

1. The Sick Doctor Scheme, Association of Anaesthetists of Great Britain and

Ireland

2. The National Counselling Service for Sick Doctors

3. Drinkline (National Alcohol Helpline)

4. Sick Doctor’s Trust (helpline for addicted physicians)

5. Local services, Church support

6. Work based support: Occupational Health Services

7. Saneline

8. Support for Re-training

9. British Medical Association Stress Counselling Service for Doctors

REFERENCES.......................................................................................... 26

SECTION I - SUMMARY

1

SECTION I - SUMMARY

1.

A stressed doctor is not necessarily a bad doctor but difficulties may

occur when the stress gets out of control.

2.

The multiplicity of support groups attests to the fact that problems

are widespread and solutions complex.

3.

The organisational difficulties in the workplace lead to an inability to

reach desired goals and produce frustration. It is  clear  that  lack  of

control and the problems of administrative responsibilities figure most

highly as stressful factors.

4.  Consultants are responsible for each other by moral obligation and for

trainees  and  non  consultant  grades  by  convention.    In  stressful

situations discussions with a friendly, understanding colleague may be

all that is required to resolve difficulties.

5.

The skills of stress management are integral to the management of

many conditions at work and in everyday life.

6.

Communication skills are basic in our personal and professional lives

and the ability to stand up for one’s rights without violating the rights

of others is important in the practice of assertiveness.  It is necessary

to  learn  to  say  no,  when  appropriate,  in  a  constructive  and  non

confrontational manner and there is need to be able, politely, to resist

unrealistic demands from others.  Some distorted beliefs may be long-

standing and encouraged by our environment.

7.

When problems occur the first action of the Clinical Director must be

to discuss the situation with the person involved or to get  another

senior  colleague  to  do  so.  Any  reported  problems  should  be

approached  with  diplomacy  and  confidentiality  must  be  respected.

However documentation, statements and witnesses are also important.

It must always be remembered that patient safety is paramount.

8.

At any stage in a consultant career support and advice may be needed.

It is not widely understood how the various support systems work.  All

directorates  should  practise  their  methodology  of  dealing  with

problems and of providing support for colleagues.  A mentor system

may be worthy of exploration.

9.  All doctors should be discouraged from self diagnosis and, especially,

self treatment.

SECTION I - SUMMARY

2

10.  Support and treatment should always be on a confidential basis.

11.  The Association of Anaesthetists  of  Great  Britain  and  Ireland  can

provide confidential guidance in all these matters.  The President or

the Senior Officers are available at all times.

SECTION II - INTRODUCTION

3

SECTION II - INTRODUCTION

Stress can be defined as mental, emotional or physical strain or tension and

is an integral part of life.  Moderate amounts of stress provide the driving

force  which  enables  mankind  to  function  optimally.    Undue  stress,

however, is eventually unsustainable and may in extreme situations result in

mental or physical  disintegration.    It  is  inevitable  that  events  both  in

personal and professional life will prove stressful.  Learning to cope with

these stresses is an important part of development.

Stress occurs when there is a perceived imbalance  between  the  demands

being made and the ability to meet those demands.  A career in medicine

attracts conscientious and introspective individuals (1) and studies suggest

that  many  doctors  lean  towards  the  so  called  type  A  personality  (2)

featuring  insecurity  of  status  and  a  high  amount  of  anxiety.    This

personality  type  is  often  associated  with  increased  aggression  and  a

constant sense of time urgency.  Type A individuals tend to be susceptible

to stress, have a higher incidence of coronary artery disease and may have

problems coping with and responding to difficult situations.  There is an

interaction between stress and psychological dysfunction.  Recent evidence

has shown that 30% of all health care workers, including doctors (3), will

experience  psychological  dysfunction  at  some  time  in  their  career.

Excessive  stress  increases  vulnerability  and  in  some  circumstances,  at

extremes, the outcome may be suicide.

It is essential to organise life so that it is possible to  cope  with  stress,

maximising  the  positive  and  minimising  the  deleterious  effects.    The

management of stress hinges on the recognition of the nature and causes of

stress  and  an  understanding  of  how  individuals  respond.    Changes  and

modifications to lifestyle can then be made to control the situation.

In the specialty of anaesthesia it is now well recognised that anaesthetists

do suffer from stress.  In a recent survey (4) 30% of  anaesthetists  felt

stressed a lot of the time while 5% felt stressed all the time; 33% described

themselves as severely stressed and 7%  felt  their  stress  was  more  than

severe.  In the work related environment the stressful elements were lack

of control (42%), strained professional relationships (25%), work overload

(24%), difficult work (6%) and potential litigation (3%).  In the area of

administrative and social factors, administrative responsibilities (42%) and

SECTION II - INTRODUCTION

4

work-home conflict (35%) were the most stressful while  money  (14%),

teaching responsibilities (6%) and peer review (4 %), were less so.

Thus it is  clear  that  lack  of  control  and  administrative  responsibilities

figure  most  highly  while  work  overload,  professional  relationships  and

work-home conflict are also significant factors.  All these stresses can be

modified in a positive way by the use of appropriate stress management

skills.

While many of the stress precipitating factors have in recent times become

more clearly apparent (5,6), the solutions are increasingly more difficult to

institute and there is still a poor understanding of the basic ways of tackling

the  situation.    All  consultants  in  a  directorate  should  be  familiar  with

potential problem areas and be aware of the signs of strain.  There  are

support mechanisms available and they should be familiar with them and

should be prepared to initiate necessary measures.  Directorates need  to

have a policy of education and caring, devoting some time to the discussion

of the existing mechanisms which are available for the support of  both

career and trainee grades.

SECTION III - ASPECTS OF STRESS

5

SECTION III - ASPECTS OF STRESS

1.

Recognition

The  stress  reaction  is  a  basic  physiological  response  to  real  or

perceived danger which enables the individual to stand and  fight  or

flee.  Modern threats, while great, are largely intellectual and the fight

or  flight  response  is  therefore  inappropriate.    The  psychological

response to stress in the 20th century appears to arise not only from

the original physical reaction but also from its suppression.  There is a

delicate balance between the positive effects of stress helping one to

rise to a specific challenge and the eventual inability  to  cope  with

constant, unremitting stressful situations.  At the extreme of inability

to cope lies suicide.  Medicine has a markedly higher rate of suicide

than other similar professional groups and within it the specialty of

anaesthesia has the unenviable distinction of having one of the higher

rates (7).

Most people can cope with stress for short periods; indeed some seem

to  relish  it.    Chronic  stress  produces  prolonged  changes  in  the

physiological state leading to alterations in both heart rate and blood

pressure  with  weight  loss  and  sleep  disturbance.    Emotional  and

behavioural  changes  occur,  demonstrated  by  increased  anxiety,

irritability and aggression and these may be accompanied by increased

use of drugs or alcohol.  Personality changes are common, with the

individual becoming cynical, paranoid or unrealistic and there may be

intellectual  impairment  with  poor  concentration,  judgement  and

creativity.  Such changes are often more readily recognised in others

than in oneself.

2.

Causes

Certain circumstances occurring at work or in one’s personal life are

particularly associated with stress.  Frustration, conflict and ‘hassle’

often occur in medicine, while the disruption of circadian rhythms is a

common  result  of  any  ‘on-  call’  schedule.    Life  changes,  even

apparently pleasant ones, have also been shown to be stressful  (8).

However, irrespective of whether the primary cause  is  domestic  or

professional, the two areas rarely remain isolated and there will often

be a spill over from the one into the other.

SECTION III - ASPECTS OF STRESS

6

When work and stressful episodes are analysed it can be shown that

they are typified by three main characteristics.  These are:

(a) Lack of control of the work environment.  This is a major area

of frustration in anaesthetic practice.

(b) Unpredictability of work leading to a high level of permanent

anxiety.  This is part of all emergency work and may need to be

taken into account in career selection.

(c) Over-extension due to being pressed beyond real or perceived

limits.  This is compounded by the current NHS climate of targets

to be met and budgets to balance.

3.

Sources

It  is  convenient  to  consider  the  sources  of  stress  as  being  from

environmental, interpersonal and personal factors. There is usually a

significant degree of overlap between these areas.

(a) Environmental.    For  all  anaesthetists  there  is  a  continually

increasing pressure for the maintenance of ever higher standards.

Continuing Medical Education and the demands for performance

indicators pressurise all doctors.  Inability to have control and to

organise  work  to  ensure  reaching  desired  goals  produces

frustration.    Irregular  hours  of  work  and  sleep  deprivation

accentuate the problem.  In addition, anaesthesia trainees face the

heavy responsibility of service work with its large proportion of

emergency  work,  coupled  with  the  increasing  necessity  to  be

successful  in  postgraduate  examinations  at  the  first  attempt.

There is danger in overextension of the individual in any of these

areas.

(b) Interpersonal.    Medicine  of  necessity  involves  working  with

people and difficult interpersonal relationships produce a stressful

environment.    For  the  anaesthetist  the  most  important

interaction is with surgeons.  This is an area of considerable stress

where  anaesthetists  may  perceive  themselves  as  powerless  to

change or control the situation.  In medicine the pressure on time

for all doctors and especially for trainees also puts a strain  on

their personal relationships. The ‘front line’  specialties  with  a

large content of emergency work have a particular problem.

SECTION III - ASPECTS OF STRESS

7

The incidence of both physical and mental  illness  is  higher  in

people who experience significant  life  changes  such  as  marital

difficulties,  bereavement,  personal  illness  or  job  loss.    Any

instability in this area is accentuated by the life style which many

doctors are forced to adopt or which they inflict on themselves.

(c) Personal

(i) Impending litigation.  Allied to the climate where there is an

increased incidence of complaints, the worry of impending

litigation  for  medical  negligence  is  a  further  source  of

personal stress.

(ii) Pressure on time.  There may also be pressures to achieve

more in less time.  Instances include delivering contracts in

an  NHS  trust  or  endeavouring  to  earn  more  in  private

practice.  These pressures actually foster and reward type A

behaviour but the demands must be kept in perspective.

SECTION IV - STRESS MANAGEMENT

8

SECTION IV - STRESS MANAGEMENT

Although some  causes  of  stress  can  be  removed,  others  will  always  be

present.  It is, however, possible to modify many of them and to control

the responses to them.  This is the basis of stress management.

While this document cannot provide extensive details of the skills required

for stress management, the simple outlines provided will give a basis on

which these skills can be built.

1.  Control

It is important that strategies are developed which can help to control

stress and it is essential to learn  how  to  recognise  the  things  that

cannot be changed.  In general the only person with the ability  to

change  is  oneself.    While  this  can  be  daunting  it  can  also  have

impressive results on relationships and interactions with others.

In the whole field of stress management it  is  essential  to  preserve

personal  time  and  to  establish  hobbies  to  act  as  a  diversion  and

counteract the undesirable effects of stress.  It is valuable to be able to

discuss major stressful areas  and  frustration  with  friends,  family  or

colleagues.    These  measures,  together  with  others  such  as  regular

physical and relaxation exercises and possibly meditation can help to

keep the stresses of work and everyday life in perspective.

Fundamental  skills  for  control  are  those  of  communication  and

assertiveness and their use in dealing with others.  In the workplace, as

an  example,  both  can  lead  to  a  decrease  in  aggression  among

colleagues.    It  is  important  to  learn  to  respond  appropriately  to

aggression  and  to  situations  of  conflict.    The  refusal  of  certain

requests, if felt necessary, should be done in a factual and constructive

way.  Anaesthetists make good managers and often have the ability to

produce  constructive  change  in  a  way  which  can  be  beneficial  to

everyone.  

Another area of control is to review the unfounded beliefs which are at

times fostered within the medical system especially among trainees.

Doctors are neither infallible nor superhuman.  All are subject to stress

and fatigue and while some hide the effects better than others it should

be acceptable to display on occasion some normal human weaknesses.

Finally, time management will allow not only the most efficient use of

SECTION IV - STRESS MANAGEMENT

9

work time but  also  the  recognition  that  time  cannot  be  expanded

infinitely to meet demands.

2.

Use of Communication Skills

The  objective  of  communication  skills  is  to  ensure  that  the

information  is  imparted  clearly  and  without  ambiguity  and  is

understood. Communication is a two way process in which listening

and  clarifying  by  questioning  on  the  one  side  is  balanced  by

explanation and reinforcement on the other.  At times the answer to a

difficult question may be achieved by reflecting the question back thus

encouraging the person to come up with the answer rather than have

the solution imposed by an outside party.  Non verbal behaviour and

body language are equally important in the way messages are conveyed

and received.

Communication skills are also the basis of the other important skill,

assertiveness. Good communication can prevent many crises  in  the

workplace and can remove many irritations which lead to undue stress

especially where these are due to misunderstanding.  Many changes are

taking place in the NHS: consultation about these changes is essential

and where possible is best done between those of equal professional

status.    Time  spent  in  communication  can  reap  great  benefits  to

morale.

3.

Use of Constructive Assertiveness

People feel anxious in both social and work situations when they are

unsure of how to speak up for what they feel is right.  They may go

along with a plan of action rather than cause unpleasantness.  This is

being unassertive and merely breeds  resentment  which  can  only  be

deleterious.  Learning when and how to say ‘ No’ for good reason will

have huge long term positive effects.  

To be assertive, thoughts, feelings and beliefs must be expressed in a

way that does not violate the rights  of  others  and  which  is  open,

direct, honest and appropriate.  In particular it is important to avoid

being aggressive when being assertive, although this may initially be

difficult.  There is an art in being assertive and in its adjustment to suit

a particular situation.  This art is best learnt with practice and with

guidance from those with experience.

SECTION IV - STRESS MANAGEMENT

10

4.

The Control of Aggression

Handling aggression directed at oneself is an art and improves  with

practice.  It is important that aggression is not met with aggression

and that personal remarks are ignored.  They may give short term

satisfaction but in the long run only demean the speaker.  Emotional

response to such remarks moves discussion on to an aggressive basis.

Instead it is better to be factual and demand facts in return.  Try to

remain calm but firm and be sure that you are clear as to what is both

reasonable and possible.  The backing of colleagues is invaluable.

On  occasion  conflict  can  ensue.    In  these  situations  the  optimal

outcomes will be achieved, if, while remaining assertive and holding on

to one’s principles, one also tries to be as co-operative as possible.

This approach often leads to the desired collaboration

.

5.

The Problem of Distorted Thinking

Medicine has the ability to foster the development of ideas and beliefs

which are not always rational.  One is that doctors should be capable

of anything and everything which is demanded of them.  Objectively

this is easily refutable but much less so in the heat of the moment or

when refusal could be implied to mean inadequacy.  Such beliefs and

unrealistic demands may stem from a feeling of general inadequacy,

are usually misplaced and require to be challenged and rationalised.

Beware of an emphasis on pessimism and do not demand too much of

yourself.  Anything less than 100% is not necessarily  total  failure.

Remember positive experiences; do not jump to conclusions and do