Transcript Management of Stress

Stress in General Practice
by
Dr. M. Feldman
Stress in General Practice
3/4 GP have been Rx for depression
Not another guide to Stress in GP 94
3000 GP alcoholic
Alibane RCGP 88
3x SMR of suicide in GP
Murray 88
Makin, Rout Cooper RCGP
1988
20 GP in Manchester
Stress due to
Interruptions
Emergency calls/Night
work
Emotional involvement
Administration
Home work interface
Financial Pulse 91
Stress due to
Night calls
Administration
Contact with dying
Dealing with relatives
Lack of recognition
24 hr cover
Solutions
Time management
Decrease interruptions
Decrease paperwork
Good staff relationship
Delegation
Exercise
Relaxation
Protected time
Howie
Stress occurs when appointment times do
not equal time required in consultation
Therefore always under pressure to catch
up
Stress and the GP Howie,
Levinson and Porter
Stress due to
Work Overload felt by 20% of GP
Indirect consultations e.g. phone
Tedium
Terminal care
Family commitments
Stress and the GP Howie,
Levinson and Porter
Type A - more commitments, difficulty
involving in family life, responds by
working faster
Type B Slows down and relaxes
Stress and the GP Howie,
Levinson and Porter
Mechanic
Withdrawers Low social, low tech
unhappy
Technicians
Low social, high tech
unhappy
Councillors
Moderns
High social, low tech
High social high tech
These are personality factors not related
Cooper Rout Foragher BMJ
89
1817 GP in England
Men more stressed than women
Demands of job
Patient expectations
Work /Home interface
Interruptions
Administration
RCGP May 89
Average GP works 73 hours per week of
which 54 hours on call
Average consultant works 41 hours per
week
1988 Journal of
Management in Med
Stress
Minor illness numbers
Chronic illness
Admin
Answers
Nurse practitioners
Counselling by CPN
Admin help
Computerisation
Not another guide to
Stress in GP August 94
75% treated for depression
Worse affected -young, single, urban areas
Stressors
Emergency calls in surgery
Night calls
Time pressure
Problem patients
Admin
Fundholding
82%
68%
68%
62%
Sick Doctors 1996
National counselling service for sick
doctors
Informal 400 per year
BMA stress counselling service
800 calls from April to June
Stress anxiety and depression
in consultants, GP and
managers 1994
27% of GP depressed
6% of hospital managers depressed
15% of GP suicidal thoughts
5% of hospital consultant suicidal
thoughts
Occ Med 1994 Ruth
Chambers
700 Staffordshire GP
13% depressed
60% exhausted or stressed on > 3/7 per
week
50% have sleep problems
Worse in 40
Stress predicted by
Anxiety
Paperwork at home > 3/7 per week
No hobbies
Sleep problems
Stress Surveys in GP
Coventry
1:3 GP suffered panic attacks in last 3/12
1994 Pulse Suffolk MAAG
Emergencies -> stress in 82%, night calls
70%
1996 Queens Uni Belfast
30% have considered leaving GP
60% do more than 2 hours per week at
home
1996 June West Midland
Survey of GP registrars
Major stressors
Family / Job conflict
Working for RCGP
Patients unrealistic expectations
Disruption of social life
Registrars better than principals for
Job satisfaction
hours of work
Worse for
Rate of pay
Recognition
Doctor Survey 1999
3002 GP’s =10% of total
53% Job
50% stressed
31%
24%
23%
20%
20%
17%
damaging health
Back Pain
Dyspepsia
Insomnia
Migraines
IBS
Depression
National primary care
research 2003
2000 principals , 600 salaried gp, 400
locums
Worst in partners, men – age 40-49
Worse since lat survey in 1998
Main factors
Workload
Paperwork
Not enough time
Stress
The confusion created when ones mind over-rides
the body’s basic desire to choke the living shit
out of some asshole who desperately needs it
Pressure or stress
Optimum performance
HIGH
p
E
R
F
O
R
M
A
N
C
E
Rustout
Burnout /
Breakdown
LOW
STRAIN / PRESSURE
21
Pressure or stress
two types of people
22
Different Perspectives
of stress
Stimulus based
 Noxious environment - heat, cold, lack of sleep
 Social ridicule / failure / bad relationships
23
Different Perspectives
of stress
Response based
General adaptation syndrome

1}Alarm reaction - defence mobilisation lowering of resistance

2}Stage of resistance - coping mechanisms
resistance restored

3}Stage of exhaustion - Adaptation declines
24
Different Perspectives
of stress
Interactional models.
 Outcome dependent on interaction between
person and environment
 Cooper - Stress due to misfit between perceived
demand and perceived abilities
 Cox - Stressor - perception of stress -> appraisal
of ability to cope -> stress reaction
25
Stress and Absence
Some Cost Estimates
 40 - 80 million working days / £1-2 billion p.a. (
HSE )
 £5.3 billion cost of certificated absence for anxiety
and depression ( CBI )
 30% of sickness absence ( BA )
 40 % of sickness absence ( Post Office )
 60% of sickness absence ( Cable & Wireless )
26
The true cost of stress
HIGH
'Optimum
Performance’
P
E
R
F
O
R
M
A
N
C
E
'Rustout'
'Burnout'
LOW
HIGH
PRESSURE
27
Marking for Stress Scale
 Q1… a=0 b=1 c=2 d=3 e=4
 Q2…1 for each “Yes”
 Q3…0 = Yes, 1 = blank , 2=
No
 Q4/4/6/7 ……... 1 for each No
 Q8……………. 1 for Yes
 Q 9-14………... 1 for No
 Q15………
a=2 b=1 c=0
 Q16………… a=0 b=1 c=2
 Q17………… a=2 b=1 c=0
 Q18………… a=0 b=1 c=2
 Q19………… a=2 b=1 c=0
 Q20………… a=0 b=1 c=2
 Q21………… a=0 b=1 c=2
 Q22 Score as the number
written
Distribution of Stress
Scores
40
35
30
25
20
15
10
5
0
<5
<10
<15
<20
<25
<30
<35
<40
Stress Scores
 Average =
14.4
 Minimum=
3
 Maximum=
40
 SD=
7
 Company Av
10.8 - 19
Company Types Average
Scores
 Financial Advisors (sm)
 Power Generation
 Agrochemical
 Chemical
 Pharmaceuticals
 Pharmaceuticals
 Pharmaceuticals
 Car Delivery
 Insurance Financial (lge)
11.1
12.0
12.7
14.4
14.6
12.5
16.2
17.5
19
Factors influencing the severity of stress
Effects of Stress
Factors influencing
the severity of stress
The Stressor

Multiplicity of stressors.

Severity and duration

Imminence of harm

Unpredictability, Ambiguity and uncertainty
33
in year leading to
redundancy
Attendance
per year
Redundancy
High rate
Normal
Rate
Time
34
Factors influencing
the severity of stress
Personal characteristics

Knowledge / beliefs / values - the event

Knowledge / beliefs / values - ability to cope

Personality characteristics

Susceptibility and anxiety
35
Factors affecting accidents
in female athletes
Social support
Social support
+
+
Coping skills
coping
skills
Social support
Coping skills
Neither
36
Factors influencing
the severity of stress
Social support

Emotional support

Information support

Tangible support
37
Factors influencing
the severity of stress
Self Esteem
Self Confidence
38
Factors influencing
the severity of stress
Self Confidence
 Experience
 Unconditional support
 Value System
 Skills:Change
Powerlessness
Lack of hostility
Not needing approval
39
Effects of Stress
Short Term
 Fight or flight
Long Term
 Physical - Many different body systems affected
 Social
- Work and home - Stress Spiral
 Psyche
- Anxiety / Depression
40
Long Term Physical
 Cardiovascular
 Reproductive
 Gastrointestinal
 Neurological
 Respiratory
 Immune
 Skin
41
Long Term Psychological
 Addiction
 Insomnia
 Depression / anxiety
42
Social
 Marital Problems
 Relationship Problems
 Stress Spirals
43
Coping Strategies
Poor
 Avoidance
 Denial
- Buck passing, running away
- What stress?
 Alcohol, smoking caffeine and other drugs
44
Graph to show effect of
alcohol and caffeine
on alertness
ALERTNES
S
COFFEE
BOOZE
COFFEE + BOOZE
SLEEP LINE
45
Coping Strategies
 Behavioural
 Symptom Reduction
 Cognitive
 Others
46
Coping Strategies
Some techniques
Coping Strategies
Behavioural

Time management

Assertiveness

Social Support
48
Coping Strategies
Symptom reduction
 Progressive Relaxation
 Relaxation through Visualisation
51
Cognitive Strategies
 Changing your perception of events
 Utilising the power of your brain to reduce
or eliminate stress
 What you think is what you feel
52
How stress effects your
thinking
 Distorted thinking, generalisations,
magnification of problems, personalisation
of events
 Automatic thoughts
 Tunnel vision
53
Selective abstraction
 Obsession with loss
Depression
 Malice of others
Anger
 Multiple Dangers
Anxiety
54
Reappraisal
 Constructive self-talk
 Quick recovery
 Thought stopping
55
Positive thinking
 Focus on the future, not the past
 Positive meanings, positive approaches
 Giving yourself support, encouragement,
messages
 Use humour
 Turn problems into opportunities
56
Behavioural / Cognitive
 Creative problem-solving
 Prevents / reduces panic; provides structure;
uses the right side of the brain as well as the left
 STATE - OUTLINE - LIST - VIEW - EVALUATE
 Stress inoculation training
 Combining diverse methods ( information
seeking, imagery, behaviour rehearsal, task
organisation, relaxation, anticipatory problem
solving ) to prevent stress
57
Coping Strategies
Other Techniques
 Goal Setting
 Hypnosis
 Meditation
 Physical Exercise
 Biofeedback
 Reflexology
 Rest and relaxation
 Homeopathy
 Retreats
 Acupressure
 Colour Therapy
58
Places to get help
Your GP
BMA councelling service
British Doctors and dentists group
British Association of councelling
COPE councelling for gp.’s
Doctors support line
Doctors support network
Stress Management
The End
Help
GP care
Health at work in the NHS
National Association for staff support
National coucselling service for Sick Drs
Sick Doctors Trust