For a variety of reasons, stress in medical practice has always been a major topic of discussion¹. Before looking into the causes and management of stress in medical professionals and students, one must first understand what stress is and the implications that it may have on an individual and others. Broadly speaking, stress can be defined as a state of physical, mental, or emotional strain or tension caused by factors known as ‘stressors’. Stressors are mainly external events and the amount of stress they cause depends on a variety of variables: magnitude, multiplicity, persistence, resolvability and timing. But some stresses come from the character of an individual, for instance someone who worries about uncertainties or fears failure. So stress can be caused by internal factors and it is someone’s resilience to stress that will affect the severity of the stress on their health.

In 1992 the British Medical Association (BMA) published a report, Stress and the Medical Profession, which showed the proportion of medical professionals experiencing stress was a concerning issue and that medical professionals were between two and three times more likely to commit suicide than other comparable populations³. This potentially could have implications on the quality of health care that the public receives, as symptoms of stress could decrease the quality of a medical professionals work. From personal experience, various injuries from sport, I have found that it is sometimes clear when a doctor is stressed, as conversations are often brief and unclear with the doctor seeming distracted. Receiving badly explained information made me feel unsure of the treatment plan and the severity of the injury. A particular case was after I broke my arm for the second time and had to undergo a second operation. I was originally told that I would have a six week recovery period by the senior consultant but further conversations with junior doctors, who often seemed rushed and unsure, gave me a recovery period of between six and fifteen weeks. It was certainly apparent that the doctors were extremely busy and some were coping better than others.

I wanted to explore why the issue of stress appeared to be of such significance in medical practice. In order to do this I discussed with other medical students to identify any themes and causes of stress in medical practice. I then produced a piece of artwork aiming to portray these ideas in a creative way.

It is certainly apparent that my peers are aware of the stresses that a career in medicine can involve. The overall consensus is that the stress is caused partly because medical practice involves taking care of the lives of others, and therefore mistakes can be potentially irreversible. Thus, there is a level of expectation of doctors, not only in society but financially, to perform to a certain standard on a constant basis. But doctors are still people and ‘all people make mistakes’. Therefore doctors may feel constantly under pressure to perform, and this may have positive effects on some but cause stress and other detrimental effects on the health of others. But Medicine’s primary aim of caring for the health of another doesn’t just create stress because of the fear of mistakes and their repercussions; there are ethical, social and emotional issues that are also highly relevant. Becoming ‘emotionally attached’ is a recurring issue and in particular, having to deal with the death of a patient. This is an aspect of medicine that we feel cannot be taught by others during training and must be learnt by the medical student through experiences. This fear of the ‘unknown’ could act as a stressor not only when having to deal with death, but also when having to deliver bad news to patients during the early stages of a doctor’s career. Not only did we feel that delivering bad news could cause stress but we also thought that the way in which the news was delivered, and the quality of performance, could be affected by being stressed. In fact, a number of studies have suggested that factors such as stress, burnout, fatigue and personal issues can affect a doctor’s ability to impart bad news sensitively⁴.

Another cause of stress discussed is the hostility of the working environment in medical practice, in particular long working hours. In the mid 1990’s some junior doctors had working weeks over 100 hours, but European rules have now restricted working weeks to 48 hours⁵. However, working hours are still higher in medical practice relative to many other careers and so the issue of tiredness and fatigue may lead to a decrease in the quality of a doctor’s performance, which in turn could cause anxiety and act as a stressor. A shorter working week for junior doctors also raises concerns that there is not enough time to teach students everything they need to know. As a first year medical student, it is the sheer volume of information that needs to be learned that I find incredibly daunting, and not having enough knowledge when actually practicing medicine would certainly cause me a good deal of stress. The length of training and the amount of examinations was another obvious cause of stress.

However, it was a particular cause of stress that was mentioned by one of the students in discussion that gave me the inspiration for my creative piece: isolation. When we discussed what she meant by ‘isolation’ it appeared to link in with many of the previous stressors already mentioned. The first reason for a doctor feeling isolated was because of the importance of the job at hand (dealing with someone’s life) and the social expectation that is therefore put upon a doctor. As medical students we all felt that, even now, we had different responsibilities and expectations to some other students. From the start of medical school we must interact with people who have illnesses, of which some are terminal, and we are bound by confidentiality. There have even been a number of occasions where a friend or a member of family has said, ‘well, I don’t know…you’re the doctor!’ So doctors may feel alone because others, who are not in medical practice, may not be able to understand the experiences that a doctor has to deal with. Therefore it seems sensible to suggest that doctors would discuss with each other the issue of stress and, where possible, members of a team would look out for signs and symptoms that indicated stress in their colleagues. However, a number of studies have shown that a particular stressor experienced by some junior doctors is workplace bullying⁶, and because of the intensity of medical practice many might not feel it is important to discuss and be aware of stress. So a doctor may feel that they are expected to overcome stressful and emotional events by themselves, and hence they could feel isolated.

To reflect the stress that a doctor may experience during their career I chose to develop a creative piece. The artwork is a mixed-media drawing/painting, using pencil, fine-liner pen and acrylic paint combined. The piece depicts a doctor sitting alone with his head in his hands, clearly after a stressful or emotional event. The reason behind the doctor’s unease is not specified; instead the viewer is free to explore these ideas for themselves. For me, the doctor looks mentally and physically drained due to a long day where several emotionally challenging events have occurred. It could be that the doctor has had to deliver bad news or witness the death of a patient. The painting is a snapshot showing how this particular doctor is trying to cope with the stress; by having time alone to contemplate and consider his emotions.

Another important element of the art piece is the lack of colour, which I thought was particularly appropriate as I wanted to focus mainly on the negative effects that stress can have in medical practice. Keeping the painting in grey scale also creates more of an emotional impact on the viewer and the jet black background highlights the isolation, another important theme in the project, which the doctor is experiencing. Overall, I am very pleased with the outcome. The concept of the painting is straightforward and self-explanatory but I think it is because of this simplicity and the execution that a powerful impact is created. When I look at the image I feel empathy for the doctor and, only to some extent, an understanding of what he has to deal with. The project has also made me more aware of the social issues and complications that are inevitable in a career in medical practice. As a first year medical student I think it is possible to distance yourself from the emotions and personal lives of patients and doctors, which will be challenged during your career. This is due to the large quantity of scientific information that has to be learned and examined, which is obviously a fundamental part of studying medicine. I also think that the painting is able to portray many aspects of stress that I explored during the assignment, in particular the issue of isolation which intrigued me. Not only is it clear that the doctor is alone, but as the viewer I can feel the doctor’s loneliness. This makes me think of how I would cope with the stresses of being a doctor and how I can imagine myself in a similar position. I can understand how the doctor may want some ‘alone time’ to contemplate and evaluate his emotions, but on the other hand, I would prefer to discuss with others to help me cope with stress. This highlights how different people will experience varying amounts of stress, due to their character traits, and how different people will have differing strategies of coping.

I’ve thoroughly enjoyed undertaking this assignment, in particular having the opportunity to create a piece of artwork. I was interested in exploring stress in medical practice because it is highly relevant to me and my peers and I feel that by looking at the causes of stress my awareness of stress and my ability to cope with it may have benefited. I have concluded that there are many underlying causes of stress in medical practice, and these will vary between individuals. Such causes of stress are long working hours, expectation of high standards and fear of mistakes, emotional involvement and isolation. I felt that the group discussion was a successful platform for the project; it opened up some issues surrounding stress that I hadn’t previously thought about, isolation for instance, which gave me the inspiration for the creative work and the reflection. But the fundamental conclusion that I have gained from the assignment is that stress in medical practice is inevitable due to the nature of the job at hand. When people’s lives are involved then the emotions and psychological health of the patient, family and the medical professionals are also involved. Because of the physiological implications stress can have on the body it is therefore important that doctors learn to cope with stress so that there is no detrimental effect on the quality of health care.

(extract from a Bristol Medical School WPC assignment)

References
¹ British Medical Association, The Morbidity and Mortality of the Medical Profession- A literature review and suggestions for future research. London: BMA; 1993.

²Dr Andrew Morrice. Emotional Factors in Health or ‘Dis-stress and Dis-ease’. Lecture at the University of Bristol. Bristol 2011.

³British Medical Association, Stress and the Medical Profession. London: BMA; 1992.

⁴Meitar D, Karnieli-Miller O, Eidelman S: The impact of senior medical students’ personal difficulties on their Acad Med. Nov 2009; 84(11):1582-94.

⁵BBC News: Cap on junior doctor hours starts. Available from: http://news.bbc.co.uk/1/hi/health/8177878.stm [Accessed 30/03/2011].

⁶Daugherty SR, Baldwin DC Jr, Rowley BD: Learning, satisfaction and mistreatment during medical internship: A national survey of working conditions. JAMA 1998; 279: 1194-9.