Work Place Stress in Obstetrician- Gynecologists in India

Introduction

Work place stress is ubiquitous phenomena that are omnipresent across various types of occupation and professions. The word ‘stresses originated from Latin word ‘stringere’ that means starvation, sting, pain and physical hardship. This terminology was first used by Selye Hans in 1936 [1]. Health care professional are one among the professions that have to work under extreme stress. Health as defined by physical, social and mental well-being and not merely the absence of disease or infirmity. A healthy working environment is one in which there is not only an absence of adversarial conditions for health but abundance of health promoting conducive Opinion surroundings [2]. Research has revealed that the most stressful type of work is that which values excessive demands and pressures that are not matched to worker’s knowledge and abilities where there is little opportunity to exercise any control and where there is little support from others [3]. High levels of stress can impair workers’ performance and result in negative behavioral and attitudinal work outcomes [4].

Why?

Obstetrician- gynecologists are no exception in medical profession who are at increased risk of facing work related stress and even to extent of suffering from post-traumatic stress disorder (PTSD) in certain conditions following a traumatic event according to DSM- IV [5]. Pregnancy and child birth are expected to be joyful times but at times can include severe complications like still birth or maternal death with very high emotional impact on physician [6, 7, 8]. It is one such disciple entrusted with the responsibility of maintaining and bringing human life and their actions have direct reflection on patient’s well-being. It entails constant interpersonal relationships and urgent emergent medical activity and hence is at greater risk of burnout and stress as they are exposed to intense physical and psychic wear and tear besides increasing risk of medical errors and possible lawsuits [9].

In a recent study by Melani A M Bass, et al. [10] conducted on members of Dutch society of Obstetrician- gynecologists using questionnaire, it was observed that out of 683 participants, 12.6% experienced work related traumatic event with an estimated prevalence of 1.5%. The above study reflects the tip of iceberg only as other events falling short of DSM-IV PTSD were not included in the study.

A comprehensive study examining burnout among physicians in Israel (in the years 1994-2001) indicated that many suffered high levels of burnout, with burnout levels rising significantly throughout the years of the study [11, 12]. These findings coincide with a study that examined burnout among American doctors in various specialties and found that burnout is more common among physicians than among other US workers [13].

In a study by Monika Bernburg, et al. [14] on 435 German hospital residents in medical training working in 6 different medical specialties participated in cross sectional study using Copenhagen Psychological questionnaire and the results show that up to 17% of physicians reported occupational stress and 9% depressive symptoms. Surgeons perceived highest levels of distress. The study suggested ensuring physicians health and plan as well implementation of suitable mental health promotion strategies by hospital management.

More so in developing country like India with enormous population, huge expectations from medical professionals and scarcity of resources the day to day stress borne by Obstetrician- gynecologists is never considered and their concerns take a back seat. A major event gets noticed thick and fast but day to day hassles and issues that jeopardize safety and quality of services provided by Obstetrician- gynecologists are least addressed [15]. The other members of doctors community also suffer from similar stress generating events , environment but unfortunately their concerns are cornered for the sake of ethical morale duty of being a doctor or gets washed away by white collard executives who consider health sector as industry thereby talk of profits and turn over . These ultimately decrease productivity, add to collateral cost and increase chances of medical errors [16, 17].

The most common triggers of work place stress are long duty hours, over worked, inadequately skilled support staff, scarcity of resources, non-supporting colleagues and an unfavorable event like maternal or fetal death, still birth, shoulder dystocia and perinatal morbidity [18, 19]. Apart from these factors other issues that indirectly contribute to stress is additional requirement of keeping oneself calm under all circumstances while maintaining interactions with the patients or relatives [20]. The external factors like: family, children, financial issues and high goals also have effect on stress levels of individuals [20].

When

The long term squeal of a stressful environment leads to physical, emotional and mental trauma causing burnout, emotional exhaustion, and depersonalization and reduced personal accomplishments [21]. The stress related symptoms are broadly categorized as cognitive, emotional, physical and behavioral [22] (Table 1).

In India where major challenge is handling excessive work load it is of paramount importance to change the mind set of public in general and authorities managing health care settings to recognize doctors as human beings and not supernatural figures or fiction character of James Bond from Hollywood. It occurs when job-relevant personal resources are constantly exceeded by work demands [23].

It is indeed an irony that doctors emotional and psychological are not addressed. There is strong need of hour that hospitals implement support strategies for all health care professional. The most commonly used coping mechanism as enunciated by American Obstetrician are – support from colleague, friend and family, cultivation of hobbies , writing research paper and indulging in religious activities [24]. Unfortunately no support protocol or may eventually lead to work conflicts and patient aggression or violence as work related adverse events as well.

Way Out

Imagine your life as a hot air balloon, now for the balloon to rise into air, we must first toss the sandbags out of it, as we let go off the sandbags the balloon is lighter and lifts off the ground. The sandbags represent our burdens and stresses as we release them we feel lighter, mind becomes quiet and muscle relax and we sail smoothly.

Culture refers to social behavior and norms found in human society encompassing the range of phenomena that are transmitted through social learning. It comprises of values such as care, empathy, courtesy, honesty, transparency and communication. The responsibility of creating a cultural rich environment rests not only on workers but also on management who can contribute by demonstration of care for staff. They need to put a human face that makes them approachable as it always pays to show that you care for your employees. It is needless to avoid unnecessary gossips at work place. Organization should provide opportunities for personal growth like training, future development, skill enhancement and create platform for junior doctors [25].

In a busy schedule everyone scrambles in morning for reaching work place on time, gulping down the breakfast, dodging through traffic so it is of importance on which note one starts the day. A good nutrition, proper planning, positive attitude and bit of exercise in the beginning of the day keep stress under control. One has to keep oneself organized as it avoids negative effects of clutter and being more efficient at work. Avoid multitasking as then comes a frazzled feeling that splits one’s focus for many people. It’s not a bad idea to avoid being a perfectionist especially when it comes to handling of emergencies, one may not be able to do everything perfectly but it’s pivotal to keep congratulating oneself to erase any pessimism that may creep in and generate stress [26].

Ways

The doctors need to adopt relaxation strategies like meditation, deep breathing exercises and mindfulness.

Mindfulness is the state of actively observing present experiences and thoughts without judging them. Start doing mind exercises by focusing on simple activities like breathing, walking, enjoying meal, this will develop skill of being able to focus professionally on a single activity without distractions and with practice it will grow stronger thereafter can be applied to different aspects of life [27].

In 1970 Herbert Benson, a cardiologist coined the term ‘relaxation response’ [28]. It can be done in two steps, it causes physiological shift in the body just opposite of the stress response. Step I a calming focus and step II let go relax. Calming focus be a small prayer, a positive word or a sound (om) or a phrase (I am relaxed, breathe in, breathe out). This maneuver heralds runaway biological changes and doing it for 10-20 minutes daily one can bring physiological changes like slowdown of heart rate and breathing reduced blood lactate levels to decline anxiety attacks. Relaxation responses can be achieved by any techniques like [29]: body scan, guided imagery, mindfulness, meditation, yoga or religious prayer. A sample distress guide is depicted in table 2 which could be help to culminate stress.

Conclusion

It is dire need for hospital to increase awareness among residents, physicians and implement standardized support after an episode of traumatic incident. Evaluation of coping strategies should be a part of medical curriculum as it is futile to read more than a dozen subjects if mind is not stable. I hope that the current article will stimulate exploration and open new avenues to this growing problem of work stress among health care professional of all specialties.