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Stress it could even happen to you

Even experienced GPs succumb to stress, as reflected in the number of GP suicides every year. Dr Sue Elliston explains how stress manifests itself and how to cope

Even experienced GPs succumb to stress, as reflected in the number of GP suicides every year. Dr Sue Elliston explains how stress manifests itself and how to cope

Medical careers are interesting and rewarding but the work can be stressful. Distressed patients, increased accountability, imposed administrative demands and frequent organisational changes all have a cumulative effect on health and wellbeing. However, it is not the external stressors per se, but how we respond to them that results in either vitality and health, or distress and disease.

Although much of the time we thrive on the buzz of the job, my experience from running two services in Wales for GPs (the North Wales Doctor Support Service and its successor, the all-Wales Primary Care Support Service) makes it evident that most of us at some point 'look into the abyss'. So it is perhaps not surprising that a number of GPs each year commit suicide for stress-related reasons. This raises a number of questions:

•Are we unaware of our own symptoms of stress despite the fact that recognising them in patients is a standard part of our clinical skills?

•Is the possibility of being stressed so unthinkable that our coping mechanism is to act as if we are immune?

•Why, when we finally recognise the symptoms, do we avoid seeking help?

Perfectionists

I think the answers lie partly in our medical training, culture and in what draws many people to the profession in the first place. Many of us have type A personalities and are perfectionists. Although this is of great benefit to our patients it often means we put unrealistic demands on ourselves. We are trained to be intensely focused on the needs of the patient, providing them with the best possible care. This is achieved at the expense of ignoring our own body's need to eat, sleep or exercise.

Even when extreme work conditions ease, this pattern of 'self-abuse' is so ingrained that we continue to ignore the feedback loops of our own needs. There is a quote in a James Joyce story in which he says: 'Mr. Duffy lived a short distance from his body.' I think many doctors have learned to do just that. When feedback loops are ignored, things start to go wrong. Schwartz has outlined a very simple model: 'Disattention leads to disconnection which results in disregulation and ultimately to disorder/disease.'

Stigma

So disattention is one factor. But there are others that have become apparent in my job. The Primary Care Support Service aims to provide an integrated approach to promoting the health and wellbeing of GPs in Wales through counselling, support and education. I make presentations at various forums of GP bodies (LMCs, GPC Wales, and so on).

What generally emerges at these meetings is very strong support for the service but with a spoken or implied response that it is important for those who need it 'but, of course, that doesn't include any of us here today'. This represents part of the old 'admitting you need help is a weakness' ethos. Interestingly, at the end of these meetings I am often approached privately by GPs who reveal they have used counselling and found it enormously helpful. There is also a sense that some GPs who have been in practice for many years feel that counselling is okay for younger doctors but not for them.

Stress manifestations

So a combination of these factors can discourage us from seeking help. Stress builds up, which may lead to a familiar range of physical symptoms. What may be less obvious, however, are the effects of chronic stress and their possible consequences as summarised in the box below.

Coping mechanisms

To compound the problem, research has shown that doctors tend to have a limited repertoire of coping mechanisms dating back to student days and traditionally employing alcohol. As we grow older and our lives change, these measures may no longer serve us. So what can be done instead? Fortunately, once you recognise the need to consider this, there are many things you can do to promote your own wellbeing.

1 Pay attention to your own needs and respond to them (such as eating, sleeping and resting). Self-care is not self-indulgence but common sense.

2 Use every opportunity to move or stretch your body during the day and build in some exercise after work.

3 Several times a day consider taking a few minutes as a breathing space, as follows:

• acknowledge the buzz in your mind

• shift your attention to experiencing your breath

• then focus on physical sensations in the body, allowing yourself to relax if possible.

Once familiar, this breathing space can even be done with patients in the room.

4 Do at least one thing a day you really enjoy, especially on the more challenging days.

5 Learn some other techniques that can easily be used during the working day.

6 Enrol on a proactive health promoting course, such as the mindfulness-based stress reduction or cognitive therapy programmes (MBSR/MBCT) that are offered in Wales by the PCSS and increasingly by others throughout the UK. These are evidence-based courses designed to help us respond to challenges in a way that can promote our wellbeing and improve our quality of life.

7 Consider the use of psychometrics (such as the Myers-Briggs Type Indicator) to help you understand how aspects of your personality might make certain situations challenging and find a way of working with this.

8 If you recognise you are struggling, seek help from others, such as a counsellor.

9 Consider using the services of organisations set up for doctors (see box below).

Dr Sue Elliston is director of the Primary Care Support Service

GP SUPPORT

• All Wales Primary Care Support Service www.primarycaresupport.wales.nhs.uk

• BMA Counselling. Confidential 24-hour telephone counselling service. 08459 200 169

• Doctors for Doctors Service (run by the BMA). Speak in confidence to another doctor. 08459 200 169

Doctors Support Network. A self-help group for doctors with mental health problems. 0870 321 0642

British Doctors and Dentists Group. For doctors and dentists in recovery from substance abuse. 01252 316976

Sick Doctors Trust. Helpline 0870 444 5163

Signs of stress

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