Stress Managementof

Post Graduate Medical Student

Dr. Md. Yunus Additional Professor

&Co-ordinator

Medical education Unit, NEIGRIHMS drmdyunus@hotmail.com

Objectives of This Talk

1. Recognize common stressors in the medical profession

2. Describe the continuum associated with unmanaged stress

3. Assess personal risk for burnout

4. Analyze the expectations and risk factors for Medical Student

that increase risk for burnout

5. Apply learned skills that enrich personal resilience, manage

stress & prevent burnout

6. Identify resources for assistance

7. Recognize when medical students need professional help

• Committee on Physician Health and Rehabilitation 401 W. 15th Street, Austin, TX 78701(512) 370-1300www.texmed.org

• Results: The prevalence of stress among the international

doctors was 54% (95% CI: 44–63%).

• The highest levels of stress were reported for “Anxiety and

Insomnia” and the lowest level was reported for “Severe

Depression”

• Journal of Clinical and Diagnostic Research. 2012 June, Vol-6(5): 859-862

J Postgrad Med. 1998 Jan-Mar;44(1):1-6.A study of stress in medical students at Seth G.S.

Medical College

• RESULTS:

• Majority of medical students (175/238-73%)

perceived stress

• Stress was found to be significantly more in

Second and Third MBBS students rather than

First MBBS levels (p < 0.05)

• The evaluation showed that the participants rated the overall

workshop as highly useful (86.9%) and as having achieved the

objectives (86.2%).

William Osler, Father of modern medicine

• Said it beautifully

“Medicine arose out of the primal

sympathy of man with man; out of

the desire to help those in sorrow,

need, & sickness”

This relationship arises out of pain & suffering of one person,

& offer of hope by another

WHAT IS STRESS ?

Stress is the reaction people have to

excessive pressures or other types of

demand placed upon them

It arises when they worry that they can’t

cope

HELP ME!

STRESS

• Stress is a part of being alive

• The only time there is a total

absence of stress is in death

Definition of Stress

• Stress is an internal process that occurs when a person is

faced with a demand that is perceived to exceed the resources

available to respond to it effectively

• where failure to deal with the demand effectively has

important and undesirable consequences

• Stress is very subjective, as it is our unique reaction to events

• Stress is defined as “our reaction to events, environmental or

internal, that tax or exceed our adaptive resources.”

S = P > R• Stress occurs when the pressure is greater than the resource

CHRONIC STRESS DIAGRAM

TYPES OF STRESSORS

•External

•Internal

EXTERNAL STRESSORS

• Physical Environment

• Social Interaction

• Organisational

• Major Life Events

• Daily Hassles

I got the answer

INTERNAL STRESSORS

• Choice of Lifestyle

• Negative self - talk

• Mind traps

• Personality traits

TYPES OF STRESS

• Negative stress

• Positive stress

Let me think…..

NEGATIVE STRESS CYCLE

POSITIVE STRESS

• Keeps you motivated

• Makes you perform

better under pressor

Eustress or positive

stress occurs when

your level of stress is

high enough to

motivate you to move

into action to get

things accomplished

EUSTRESS

SYMPTOMS OF STRESS

• Physical symptoms

• Mental symptoms

• Behavioural symptoms

• Emotional symptoms

Physical Symptoms of Stress

MENTAL SYMPTOMS

• Lack of concentration

• Memory lapses

• Difficulty in making decisions

• Confusion

• Disorientation

• Panic attacks

BEHAVIOURAL SYMPTOMS

• Appetite changes - too much or too little

• Eating disorders - anorexia,

• Increased intake of alcohol & other drugs

• Increased smoking

• Restlessness

• Fidgeting

• Nail biting

EMOTIONAL SYMPTOMS

• Bouts of depression

• Impatience

• Fits of rage

• Fearfulness

• Deterioration of personal hygiene

STRESS RELATED ILLNESSES

Stress is not the same as ill-health, but has

been related to such illnesses as;

• Cardiovascular disease

• Immune system disease

• Asthma

• Diabetes

Effects of Stress

• Digestive disorders

• Ulcers

• Skin complaints - psoriasis

• Headaches and migraines

• Pre-menstrual syndrome

• Depression

COSTS OF STRESS

80% of all modern diseases have their origins in

stress

Many working days per year are lost directly from

stress - related illness

The Challenges in Medical College

• The best years of your life? Expectations..

• Even positive change is stressful

• Greater academic demands

• Unstructured time

• Decreased adult availability

• Being on your own in a new environment

• Changing relations with family

Stressors in Medical Institute

• Dramatic lifestyle changes

• Heavy academic

workload/clinical caseload

• Perceived need to excel at all

costs

• Lack of control/autonomy

• Responsibility for patients

• Exposure to infections

• Limited support systems

• Inadequate training for

working with patients &

families

• Frenetic, intense pace of

training

• Repetitive single tasks/scut-

work

• Problems without solutions

• Death & dying

• Time pressure & demands

• Disillusionment

Academic stressors

• Students never have enough time to study

• Experiences fears of increasing responsibility,

death of patients, fear of Failure

Clinical stressors

• Clinical stressors include difficulties in dealing with the chain of

command/ pecking order common for students

• Coping with hierarchy & the authoritative environment is troubling

for students

• “Student compares medical training to military training”

• Both recruit young people full of leadership potential and

essentially break their autonomous will through a rigorous

hierarchy

• Students are thrown into the hospital wards-definitely

front-line duty like in War

Expectation From doctors

• The culture of medicine has created an unrealistic

expectation of doctors to always put the patient first and

to deny their own needs

• In their role as healer, it is hard for physicians to

accept help for themselves, or reveal that they are

facing personal challenges

The Process of Stress

1. Stress leads to arousal

2. Person selects a coping response

3. If effective, arousal decreases

4. If ineffective, arousal increases, resulting in

escalation of stress level

5. Unresolved stress leads to burnout

6. Burnout leads to unethical behaviours

Three Stages of Burnout

• Stage 1 — Stress Arousal

• Stage 2 — Energy Conservation

• Stage 3 — Exhaustion

Stage 1 — Stress Arousal

• Irritability, anxiety

• Insomnia

• Forgetfulness/Poor concentration

• Gastrointestinal disorders

• Headaches

• Self-medication

With the presence of any two of these, on may be experiencing Stage 1 stress arousal

Stage 2 — Energy Conservation

• Lateness, procrastination

• Excessive time off

• Decreased sex drive

• Fatigue

• Social withdrawal

• Increased substance abuse

• Again, any two of these symptoms may signal that one is in Stage 2 of the burnout cycle

Stage 3 — Exhaustion

• Chronic sadness or depression

• Suicidal ideation

• Chronic GI problems & /or headaches

• Social isolation

• Substance Use Disorders

• Unethical behaviours (disruptive behaviour, boundary

violations)

Definition of Burnout

• Burnout is a state of mental & / or physical

exhaustion caused by excessive and prolonged stress

• Burnout syndromes are characterized by three

features:

– Emotional exhaustion,

– Depersonalization (cynicism), &

– Diminished sense of personal accomplishment

Burnout Survey Results

• Fifty percent of all medical students were

assessed with significant burnout in a large

multicenter study

• Physician burnout has a negative impact on

patient outcomes

Risk Factors for Burnout

• Perfectionism & control to reveal emotions equals

weakness

• Pressure that patients should always come first

– Overachievers: Type A personality

– Reluctance to ask for help

– Belief that physicians do not have needs

Negative Outcomes

• Addictive behaviours

• Relationship distress

• Emotional/Behavioral problems

• Loss/Lack of spirituality

• Academic consequences

• Death/Suicide

Current Medical Student Drug Use

• 10 to 15 percent of all health care professionals will

inappropriately use drugs or alcohol at some point during

their careers

• 15 percent of medical students scored positive for at-risk

drinking.

• 33.4 percent of medical students reported using one or

more illicit drugs in the past year.

• 16.8 percent of medical students report lifetime use of

“club drugs” (MDMA,cocaine)

Susceptibility to Depression

• More than 20 percent of medical students have symptoms of

depression

(12 percent — probable major depression and

9 percent —probable mild/moderate depression)

• Up to 9 percent of students reported suicidal ideation

• Prevalence of depression increases over the course of

medical school, with a higher risk of stress/depression

associated with transition to clinical care rotations (third

year)

What is ’Stress Management’?

The

art

of

taking

care

of

oneself

Our goal is not to eliminate stress but to learn how to manage and use it to

help us

.

STRESS CONTROL

ABC STRATEGY

ABC STRATEGY

A = AWARENESS

What causes you stress?

How do you react?

ABC STRATEGY

B = BALANCE

There is a fine line between positive / negative stress

How much can you cope with before it becomes negative ?

ABC STRATEGY

C = CONTROL

What can you do to help yourself combat the negative effects of

stress ?

Tips to Handle Stress

• Work smarter, not harder

• Carry reading material with you

• Accept the fact that time will be spent on

activities outside your control

• Record daily activities, achievements,

goals, sources of delay, & time wasted

to realize hidden opportunities

Tips to Handle Stress

• Always maintain a short task list

• Continually ask yourself ”What is the best use of

my time right now”?

• Be physically active to relieve tension

• Make quick decisions

• Carefully mix work & breaks

• Have a positive attitude

• Relax

Suicide Is Preventable

• Feelings of hopelessness

• Continuing thoughts or wishes for death,

• Feelings of being trapped

• Personal losses such as death of a loved one

• A broken relationship are signals that a

consultation with a health professional would

be beneficial

Self-Assessment Exercise

Self-assessment exercise to assess your own personal stress level

• This exercise is for your own use and does not need to be returned to Me

• How often do you … Calculate your total score as follows:

(a) almost always (a) = 4 points;

(b) often (b) = 3 points;

(c) seldom (c) = 2 points;

(d) almost never (d) = 1 point

Total = ------

1. Find yourself with insufficient time to do things you really enjoy?

2. Wish you had more support/ assistance?

3. Lack sufficient time to complete your work most effectively?

Self-Assessment Exercise Conti…..

4. Have difficulty falling asleep because you have too much onyour mind?

5. Feel people simply expect too much from you?

6. Feel overwhelmed?

7. Find yourself becoming forgetful or indecisive because you have too much

on your mind?

8. Consider yourself to be in a high pressure situation?

9. Feel you have too much responsibility for one person?

10. Feel exhausted at the end of the day?

Overload

• This exercise was designed to assess your level

of stress due to overload

• Overload or over-stimulation, refers to the state

in which the demands around you exceed your

capacity to meet them

Four major factors in overload

(1)Time pressures

(2) Excessive responsibility or accountability

(3) Lack of support &

(4) Excessive expectations from yourself & those

around you

Any one or a combination of these factors can result in stress

from overload

• A total of 25-40 points indicates a high stress level, one

that could be psychologically and physiologically

debilitating

Preventing Burnout• Maintain a sense of optimism

• Work on friendships and support systems

• Take care of yourself/do not overextend yourself:

– Exercise regularly/eat right

– Get enough sleep and

– Take time to play

• Keep a sense of humor

• Have a hobby that is relaxing & enjoyable

• Choose specialty residency wisely; remember you can change your mind

• Get help if you need it

• The key is to not try to avoid stress altogether, but to recognize and

manage the stress in our lives in such a way that we avoid the negative

consequences of stress

EXERCISE

EXERCISE AND STRESS

• Exercise increases blood flow to the brain which is good for us

• Exercises also releases hormones, and stimulates the nervous system

in ways that are good for us

• Exercise produces chemicals in the body such as beta-endorphin,

which is proven to have a positive effect on how we feel

Balanced DIET

• AVOID Caffeine, Tobacco and Alcohol

YOGA/DHYANA

• Exercise burns up adrenaline and produces helpful chemicals

and positive feelings

SLEEP AND REST

• .

Mental Techniques

. M - Money Management, Minimize needs, Meditation

• E - Earnest Expectations, Enjoy the work you do

• N - Avoid Negative thinking

• T - Try to be happy Today

• A - Accept and Adopt Reality

• L - Avoid Loneliness

• H - Develop good Hobbies

• E - Live in good Environment. Express yourself clearly

• A - Be Active and have positive Attitude

• L - Try to Learn more & Manage Life

• T - Have realistic Targets & Tackle one at a time

• H - Maintain Healthy life style

Potential Barriers

• Stigma

• Residency

• Professional Carrier

Summary

• Stress is inevitable

• Burnout is preventable, treatable, & manageable

• Identify coping strategies that work best for you

• Help is available

Created by Dr. Md. Yunus for Medical

Students to Beat Stress & Enjoy the

work & world

Email: drmdyunus@hotmail.com

Web: www.neigrihms.nic.in