Stress in General Practice by Dr. M. Feldman Stress in

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Stress in General Practice

• by
• Dr. M. Feldman

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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

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Makin, Rout Cooper RCGP 1988

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

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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

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Howie

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

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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

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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

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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

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Cooper Rout Foragher BMJ 89

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

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RCGP May 89

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

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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

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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

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Sick Doctors 1996

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

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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

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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

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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

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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

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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

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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

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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
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Pressure or stress
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Pressure or stress two types of people
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Different Perspectives of stress

• Stimulus based
• Noxious environment - heat, cold, lack of sleep
• Social ridicule / failure / bad relationships

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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

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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

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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 )

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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
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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

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Distribution of Stress Scores
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Stress Scores

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

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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

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• Factors influencing the severity of stress
• Effects of Stress

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Factors influencing the severity of stress

• The Stressor
• Multiplicity of stressors.
• Severity and duration
• Imminence of harm
• Unpredictability, Ambiguity and uncertainty

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Frequency of Consultations in year leading to
redundancy
Attendance per year
Redundancy
High rate
Normal Rate
Time
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Factors influencing the severity of stress

• Personal characteristics
• Knowledge / beliefs / values - the event
• Knowledge / beliefs / values - ability to cope
• Personality characteristics
• Susceptibility and anxiety

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Factors affecting accidents in female athletes

• Coping skills

• Social support
• Coping skills

Social support coping skills

• Neither

• Social support

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Factors influencing the severity of stress

• Social support
• Emotional support
• Information support
• Tangible support

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Factors influencing the severity of stress
Self Esteem
Self Confidence
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Factors influencing the severity of stress

• Self Confidence
• Experience
• Unconditional support
• Value System
• Skills-
• Change Lack of hostility
• Powerlessness Not needing approval

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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

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Long Term Physical

• Cardiovascular
• Gastrointestinal
• Respiratory
• Skin

• Reproductive
• Neurological
• Immune

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Long Term Psychological

• Addiction
• Insomnia
• Depression / anxiety

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Social

• Marital Problems
• Relationship Problems
• Stress Spirals

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Coping Strategies

• Poor
• Avoidance - Buck passing, running away
• Denial - What stress?
• Alcohol, smoking caffeine and other drugs

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

• Behavioural
• Symptom Reduction
• Cognitive
• Others

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Coping Strategies

• Some techniques

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Coping Strategies

• Behavioural
• Time management
• Assertiveness
• Social Support

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Behavioural StrategiesTime management

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

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Behavioural StrategiesAssertiveness

• Broken Record
• Fogging
• Negative Assertion
• Negative Enquiry

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Coping Strategies

• Symptom reduction
• Progressive Relaxation
• Relaxation through Visualisation

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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

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How stress effects your thinking

• Distorted thinking, generalisations,
  magnification of problems, personalisation of
  events
• Automatic thoughts
• Tunnel vision

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Selective abstraction

• Obsession with loss Depression
• Malice of others Anger
• Multiple Dangers Anxiety

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Reappraisal

• Constructive self-talk
• Quick recovery
• Thought stopping

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Positive thinking

• Focus on the future, not the past
• Positive meanings, positive approaches
• Giving yourself support, encouragement, messages
• Use humour
• Turn problems into opportunities

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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

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Coping Strategies

• Other Techniques
• Goal Setting
• Meditation
• Biofeedback
• Reflexology
• Homeopathy
• Acupressure

• Hypnosis
• Physical Exercise
• Rest and relaxation
• Retreats
• Colour Therapy

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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

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Stress Management

• The End

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Help

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