Integrated Medical Education Resources: 131210L

Lecture for medical students Faculty of Medicine, King Fahad Medical City, Riyadh Saudi Arabia on December 10, 2013 by Prof Omar Hasan Kasule Sr.

Learning objectives

· To identify typical stressors in the life of a health care professional

· Introduce a range of strategies for dealing with stress

Key words:

· Stress management

· Stress coping strategies

Issues for discussion

· Stress and time pressures as experienced by themselves and others

· The positive and negative aspects of stress

· Practical strategies for coping with stress

Definition of stress

· Stress is a psychological, emotional, and physiological reaction to a stressor. It is considered part of normal human adaptation if it is within certain limits.

· Stress becomes abnormal or pathological in situations of over-reaction such that the adverse consequences of the stress reaction cancel out the advantages.

· The stress threshold varies from person to person and from stressor to stressor. What stresses one person may not stress another one. The same individual could react to the same stressor in different ways depending on the social and personal context.

· The underlying cognitive and spiritual qualities modulate reaction to stressors.

Prevalence of stress in students

· High levels of psychological stress in Jordanian dental students[1]

· High levels of stress among Nigerian medical students with psychological morbidity[2]

· Malaysian students: 18.6% had moderate and 5.1% had severe stress[3]

Prevalence of stress in physicians

· High prevalence

· Varies by practice and work situations

Causes of stress-general

· Stressful events are traumatic, uncontrollable, and unpredictable.

· It is part of human nature to be inpatient. Thus when confronted by a problem that cannot be resolved quickly they become stressed.

· Patience is called for in moments of difficulty. However many people when in trouble forget this and fall into stress.

· Life is full of difficulties. Each difficulty is accompanied by what makes it easy.

Causes / correlates of stress – medical student

· No association between consumption of caffeinated beverages and academic stress[4]

· Perceived stress in French students associated with alcohol misuse, eating disorders and cyber addiction[5].

· Stress in Chinese students associated with coping strategies and depression[6]

Causes / correlates of stress – practicing physician 1

· Relation between stress and work varies by country and also by professional autonomy[7]

· Job satisfaction and higher rewards associated with less stress in physicians[8]

· Underlying personality determines development of stress[9]

· Long working hours and occupational stress associated with depression[10]

· Stress related to depression[11]

· Stress in academic physicians related to time pressure and conflict of interest[12]

· Younger physicians experience more stress[13]

Causes / correlates of stress – practicing physician 2

· Physicians in emergency service experience more stress[14] [15]

· Working in a neonatal unit was more demanding for physicians[16]

· Collaboration with other healthcare providers, and access to specialised services was a cause of stress among primary care physicians[17].

· Sleep quality related to stress[18]

· Workplace environment had an effect on stress[19]

Reaction to stress

· Psychological reactions to stress is anxiety, anger, aggression, apathy and depression, cognitive impairment.

· The physiological reaction to stress manifests as the usual signs of adrenaline releases. Stress associated with ECG changes[20]. Professional stress in physicians was associated with markers of inflammation that could related to cardiovascular effects[21]. Physicians on night call had more arythmias and increased neuro endocrine response[22]

· Stress caused disordered eating in female students[23].

· Long-term stress affects good health.

Coping with stress 1

· People cope with stress in different ways. Coping with stress may be by denial, projection, repression, rationalization, or reaction formation.

· The type of reaction also depends on the personality type, spiritual preparation, and experience in life. The underlying psych capital determines reaction to and coping with stress[24].

· The quickest treatment for stress is to remove the stressor. This however does not always succeed in returning the person to the normal state because memories of unpleasant stressors may continue eliciting stressful reactions for a longer time.

Coping with stress 2

· Cognitive approach to stress is to make the person realize that there is no rational basis for the stress over-reaction. Cognitive behavioral therapy[25] [26] [27]

· Spiritual approaches involve repairing the relation to the Creator so that the victim feels empowered to cope more effectively with the stressor or even ignore it altogether.

· Others: Chewing gum reduced stress[28]

Eliminating the trigger:

· Emotional disequilibrium is a disease that must be treated. Every disease has a treatment.

· Once emotional disorders have occurred, the best approach is to remove the cause if it can be identified.

· Then we undertake the task of rebuilding, repairing, and restoring faith. This is supplemented by supplication,

Restoration of faith:

· The most effective approach to dealing with emotional disorders is to correct the faith. This requires clarifying certain relationships and clarifying the issues of causality.

· A person must know the correct relation with God, with his own body, with other humans, and with the eco-system. Any defect in any one of these relationships will lead to emotional disequilibrium.

· Understanding causality removes a big burden of guilt from a person for what has gone wrong. Nothing happens without God’s permission. This however does not remove personal responsibility for actions.

Cognitive approach:

· Empirical analysis of the problem may lead us to conclude that it is not worth worrying over. We need to understand that problems are a test. The final result is not having a problem but knowing how to deal with it.

· Ignorance of human limitations (physical, cognitive, sensory) makes humans stress themselves over failures. If they were wiser they would not blame themselves because they would known that some tasks are beyond their ability.

· Human perception is not accurate. What is perceived as a problem may not be a significant problem or may not a problem at all and this would become obvious with passage of time.

· Counseling was found to decrease physician stress in a 3-year cohort follow up[29]

Supplication

· Supplication is very effective in dealing with emotional disturbances.

· Its effects are dual. On one hand there is supplication to God to relieve the stress. On the other hand there is the feeling of relief because the problem has been referred to a higher and stronger power

References

[1] J Dent Educ. 2011 Aug;75(8):1107-14

[2] Niger J Clin Pract. 2009 Jun;12(2):128-33.

[3] Asian J Psychiatr. 2013 Aug;6(4):318-23

[4] P R Health Sci J. 2013 Jun;32(2):95-100.

[5] BMC Public Health. 2013 Aug 6;13:724.

[6] BMC Public Health. 2011 May 19;11:352.

[7] Soc Sci Med. 2010 Jul;71(2):298-304.

[8] Int Arch Occup Environ Health. 2012 Oct;85(7):819-28.

[9] Int J Emerg Ment Health. 2012;14(4):257-68.

[10] Occup Med (Lond). 2011 May;61(3):163-70.

[11] Ind Health. 2011;49(2):173-84. Epub 2010 Dec 16.