Stress in General Practice

1
Stress in General Practice

• by
• Dr. M. Feldman

2
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

3
Makin, Rout Cooper RCGP 1988

• 20 GP in Manchester
• Stress due to
• Interruptions Emergency calls/Night work
• Emotional involvement
• Administration
• Home work interface

4
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

5
Howie

• Stress occurs when appointment times do not equal
  time required in consultation
• Therefore always under pressure to catch up

6
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

7
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

8
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 tech
• These are personality factors not related to
  input in medical school

9
Cooper Rout Foragher BMJ 89

• 1817 GP in England
• Men more stressed than women
• Demands of job
• Patient expectations
• Work /Home interface
• Interruptions
• Administration

10
RCGP May 89

• Average GP works 73 hours per week of which 54
  hours on call
• Average consultant works 41 hours per week

11
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

12
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

13
Sick Doctors 1996

• National counselling service for sick doctors
• Informal 400 per year
• BMA stress counselling service
• 800 calls from April to June

14
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

15
Occ Med 1994 Ruth Chambers

• 700 Staffordshire GP
• 13 depressed
• 60 exhausted or stressed on gt 3/7 per week
• 50 have sleep problems
• Worse in 40
• Stress predicted by
• Anxiety
• Paperwork at home gt 3/7 per week
• No hobbies
• Sleep problems

16
Stress Surveys in GP

• Coventry
• 13 GP suffered panic attacks in last 3/12
• 1994 Pulse Suffolk MAAG
• Emergencies -gt 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

17
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

18
Doctor Survey 1999

• 3002 GPs 10 of total
• 53 Job damaging health
• 50 stressed
• 31 Back Pain
• 24 Dyspepsia
• 23 Insomnia
• 20 Migraines
• 20 IBS
• 17 Depression

19
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

20
Stress
The confusion created when ones mind
over-rides the bodys basic desire to choke the
living shit out of some asshole who desperately
needs it
21
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
• 1Alarm reaction - defence mobilisation -
  lowering of resistance
• 2Stage of resistance - coping mechanisms
  resistance restored
• 3Stage 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 -gt
  appraisal of ability to cope -gt 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
The true cost of stress
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
28
Marking for Stress Scale

• Q1 a0 b1 c2 d3 e4
• Q21 for each Yes
• Q30 Yes, 1 blank , 2 No
• Q4/4/6/7 ... 1 for each No
• Q8. 1 for Yes
• Q 9-14... 1 for No

• Q15 a2 b1 c0
• Q16 a0 b1 c2
• Q17 a2 b1 c0
• Q18 a0 b1 c2
• Q19 a2 b1 c0
• Q20 a0 b1 c2
• Q21 a0 b1 c2
• Q22 Score as the number written

29
Distribution of Stress Scores
30
Stress Scores

• Average 14.4
• Minimum 3
• Maximum 40
• SD 7
• Company Av 10.8 - 19

31
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

32

• 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
Attendance per year
Redundancy
High rate
Normal Rate
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

• Coping skills

• Social support
• Coping skills

Social support coping skills

• Neither

• Social support

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
Graph to show effect of alcohol and caffeine on
alertness
46
Coping Strategies

• Behavioural
• Symptom Reduction
• Cognitive
• Others

47
Coping Strategies

• Some techniques

48
Coping Strategies

• Behavioural
• Time management
• Assertiveness
• Social Support

49
Behavioural StrategiesTime management

• Chose your time - energy cycles
• Establish priorities and objectives to provide
  focus
• Improve time management - discontinue, delegate,
  improve use of time

50
Behavioural StrategiesAssertiveness

• Broken Record
• Fogging
• Negative Assertion
• Negative Enquiry

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

59
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

60
Stress Management

• The End

61
Help

• GP care
• Health at work in the NHS
• National Association for staff support
• National coucselling service for Sick Drs
• Sick Doctors Trust