A structured approach to better diabetes care
Colin has taken two months to recover from back pain. He has finally gone back to work as a baggage handler, but he is not sleeping well and feeling very anxious. Colleagues talk behind his back and his employer is being unsupportive and refuses to put him on light duties. His wife thinks he has been very short-tempered with her and the children since starting work again. Dr Tanvir Jamil discusses.
Doctors are stressed all the time. What is the big deal about stress?
You're going to see a lot of it. One in five reported health problems at work is due to stress and almost seven million working days are lost through stress each year. We all know stress is a natural reaction and that a little stress is often good thing.
But when stress exceeds a person's coping skills or 'coping capacity' it starts to become a problem. Chronic or excessive stress can lead to physical and mental illness.
What behavioural changes can it cause?
Colin has a classic change caused by stress – irritability. He has become short-tempered and angry. Other behavioural changes to look for or ask about include:
lUse of alcohol, smoking and drugs – such as drink driving?
lEating – anorexia or over-eating?
lWork performance – such as a recent warning from a manager?
lAccidents at work (increase)
lTime off work – review pattern over the past year
lChange in family relationships, sex
lInability to cope with normal events – such as driving to the shops, interacting with relatives.
Are there any other points in the history that specifically point to a stress-related problem?
Look for symptoms of anxiety and depression such as early-morning awakening, tired all the time, poor concentration, palpitations, tremor, feelings of guilt and worthlessness. Remember that the patient, especially if male, may have had these problems many months before seeking help.
What work-related factors cause stress?
The main factors include:
lRelationship with managers and colleagues – ask about bullying? Racism? Sexual harassment?
lEmployers –- are they supportive?
lJob – low pay? Target related? Commission based? Long hours? Travel – away from family due to work?
What sort of general management plan should I be thinking about?
lIdentify underlying precipitating events and steps taken by the patient to modify or cope with the situation.
lExclude a physical or drug cause for the symptoms (drug or alcohol withdrawal, hyperthyroidism).
lIdentify others who might help – Relate, Citizens' Advice Bureau, union representative.
lReview what support can be obtained from family, friends, work colleagues and sources of community support.
lDiscuss coping strategies.
lAssess the need for counselling.
lDecide if short-term time off work might be helpful.
lChange of job – part-time, light duties. Would a letter from you help? With the patient's permission, could you talk to a manager or occupational health department (if available)?
What sort of coping strategies?
Exercise certainly seems to help – 20-30 minutes three times a week helps to boost the body's endorphin levels. A sensible balanced diet is also advisable – reducing or stopping caffeine-containing drinks, plenty of fruit and vegetables, and lots of water (about two litres a day total fluid intake). Good 'sleep hygiene' is essential to the management of stress. So advise about avoiding alcohol/ caffeine/smoking before bedtime, avoiding cat-naps, and thinking about milky drinks or a warm bath before retiring. A good sleep leaflet is worth giving out to patients.
Relaxation techniques should also be discussed. There is plenty of information available from bookshops, libraries and online. One of the most effective stress-relieving techniques you can teach patients is 'progressive muscular relaxation'. Stress causes tension to build up in muscles and this can be alleviated using this technique:
lMain points: stretch or tense; hold for five seconds; relax for 10 seconds.
lStand comfortably, stretch up with your right hand as high as you can, fingers outstretched. Let your arm fall and relax. Repeat with left arm, then both arms.
lThen stretch sideways similarly.
lSit in a good supporting chair. Right leg – point your toe down and stretch as far as possible and relax. Then point toe up and repeat. Do same with left leg.
lButtocks – squeeze as much as possible, and relax; repeat 3x.
lPull in your stomach, hold it in, and relax; repeat 3x.
lHunch up right shoulder; hold, and relax; repeat 3x; then left shoulder; then both.
lMake a tight fist with your right hand; hold, and relax; repeat 3x; then left hand.
lNeck – stretch; make it longer; hold, and relax; repeat 3x.
lOpen your mouth, as big as possible; hold, and relax.
lFrown between your eyes; wrinkle up your forehead; screw your eyes up tight. Do each in turn. Hold and relax. Repeat each 3x.
Colin's manager has asked for a medical report – can I provide one to a non-medic?
You should always have the patient's written consent before supplying any report – verbal or written. Do remind patients they have the right to see a report before it is sent off. If the report is to a non-medical person it should supply the essential facts and need not go into the medical details.
Tanvir Jamir is on sabbatical in Canada