Stress in General Practice

byDr. 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 ManchesterStress 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 High social, low tech

Moderns High social high techThese are personality factors not related

to input in medical school

Cooper Rout Foragher BMJ 89

1817 GP in EnglandMen 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

Occupational Stress in GP 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 82% Night calls 68% Time pressure 68% Problem patients 62% Admin Fundholding

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 depressed6% of hospital managers depressed

15% of GP suicidal thoughts5% 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 40Stress 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 damaging health 50% stressed

31% Back Pain24% Dyspepsia23% Insomnia20% Migraines20% IBS17% Depression

National primary care research 2003

2000 principals , 600 salaried gp, 400 locums

Worst in partners, men – age 40-49Worse since lat survey in 1998Main 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

21

Optimum performance

Burnout /Breakdown

Rustout

HIGH

LOW STRAIN / PRESSURE

pERFORMANCE

Pressure or stress

22

Pressure or stress two types of people

23

Different Perspectives of stress

Stimulus based

Noxious environment - heat, cold, lack of sleep

Social ridicule / failure / bad relationships

24

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

25

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

26

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 )

27

HIGH

'Optimum

Performance’

P

E

R

F

O

R

M

A

N

C

E

'Rustout' 'Burnout'

LOW HIGH

P R E S S U R E

The true cost of stress

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

0

5

10

15

20

25

30

35

40

<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) 11.1 Power Generation 12.0 Agrochemical 12.7 Chemical 14.4 Pharmaceuticals 14.6 Pharmaceuticals 12.5 Pharmaceuticals 16.2 Car Delivery 17.5 Insurance Financial (lge) 19

Factors influencing the severity of stress

Effects of Stress

33

Factors influencing the severity of stress

The Stressor

Multiplicity of stressors.

Severity and duration

Imminence of harm

Unpredictability, Ambiguity and uncertainty

34

Frequency of Consultations in year leading to redundancy

High rate

NormalRate

RedundancyAttendanceper year

Time

35

Factors influencing the severity of stress

Personal characteristics

Knowledge / beliefs / values - the event

Knowledge / beliefs / values - ability to cope

Personality characteristics

Susceptibility and anxiety

36

Factors affecting accidents in female athletes

Social support+

Coping skills

Social support

Coping skills

Neither

Social support+

coping skills

Social support+

coping skills

37

Factors influencing the severity of stress

Social support

Emotional support

Information support

Tangible support

38

Factors influencing the severity of stress

Self Esteem

Self Confidence

39

Factors influencing the severity of stress

Self Confidence

Experience Unconditional support Value System Skills:-

Change Lack of hostility

Powerlessness Not needing

approval

40

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

41

Long Term Physical

Cardiovascular

Gastrointestinal

Respiratory

Skin

Reproductive

Neurological

Immune

42

Long Term Psychological

Addiction

Insomnia

Depression / anxiety

43

Social

Marital Problems

Relationship Problems

Stress Spirals

44

Coping Strategies

Poor

Avoidance - Buck passing, running away

Denial - What stress?

Alcohol, smoking caffeine and other drugs

45

ALERTNESS

COFFEE

SLEEP LINEBOOZE

COFFEE + BOOZE

Graph to show effect of alcohol and caffeine on alertness

46

Coping Strategies

Behavioural

Symptom Reduction

Cognitive

Others

Coping Strategies

Some techniques

48

Coping Strategies

Behavioural

Time management

Assertiveness

Social Support

51

Coping Strategies

Symptom reduction

Progressive Relaxation

Relaxation through Visualisation

52

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

53

How stress effects your thinking

Distorted thinking, generalisations, magnification of problems, personalisation of events

Automatic thoughts

Tunnel vision

54

Selective abstraction

Obsession with loss Depression

Malice of others Anger

Multiple Dangers Anxiety

55

Reappraisal

Constructive self-talk

Quick recovery

Thought stopping

56

Positive thinking

Focus on the future, not the past

Positive meanings, positive approaches

Giving yourself support,

encouragement, messages

Use humour

Turn problems into opportunities

57

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

58

Coping Strategies

Other Techniques

Goal Setting

Meditation

Biofeedback

Reflexology

Homeopathy

Acupressure

Hypnosis

Physical Exercise

Rest and relaxation

Retreats

Colour Therapy

Places to get help

Your GPBMA councelling serviceBritish Doctors and dentists groupBritish Association of councellingCOPE councelling for gp.’s Doctors support lineDoctors 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