FREE ARTICLE ON STRESS MANAGEMENT COPING STRATEGIES

PRACTICE MANAGEMENT
It's 3:00 in the afternoon. There's a waiting room full of patients, and you're just starting on your 1:30 PM appointment. You still have to read through and initial all the progress notes you dictated yesterday, and study yet more referral restrictions recently mandated by the managed care executives. Wasn't it enough that you had to sit through an hour - long meeting this morning on "economies of time" that actually was designed to encourage you to spend even fewer minutes with each patient? Your morale hits a new low as you glance over the office manager's memo reminding staff of the need to cut the "extras." You can't help but wonder, "What extras?" as you look at the cache of pens you stockpiled from the last continuing education meeting you attended.

There's no doubt you see too little of your children, who always demand more energy and attention than you have to spare. Your spouse tells you that you're irritable all the time. And you lie awake at night wondering how you lost control of your career, doubting what it was that attracted you to healthcare in the first place.

But what really annoys you is Cindy, the other midlevel provider with whom you work. Cindy goes blithely through life, seemingly untouched by the same stresses that are totally devastating you. There must be something more than "type A" and "type B" personalities at variance. How does Cindy cope with this insanity while you're practically having a nervous breakdown?

To help you sort out and manage the stress in your professional life, this article looks at some of the underlying causes of stress and then proposes ways to manage anxiety - provoking situations.

WHAT CAUSES STRESS?

You Broke My Rule
Let's begin with the waiting room full of patients, and being behind schedule. Why would this cause stress for some people and not others? Start by recalling the rules imposed on you during your childhood. How did your parents or guardians treat you when you were late? Was being an hour late okay with them, or was it cause for concern (or perhaps even for punishment)?

Most of us incorporated the "rules" that were created in our childhood into our adult behaviors. Often, we adopted the rules subconsciously, so we may not even know the extent to which they govern our lives. We are, however, painfully aware of the stress they produce: we get pretty upset when someone else breaks our rules, and we become incensed when we ourselves are the culprits. That's why the first step to stress management involves looking for patterns in our lives . . . patterns that give us insight into the subconscious rules regulating our day - to - day behaviors.

Time - consuming, Boring, and Unimportant
What about the second stress mentioned above: paper work? Very few healthcare practitioners enjoy the forms to be filled out, notes to be written, and memos to be read. Paperwork is certainly not the reason people in the caring professions selected their careers.

Paperwork is, however, a necessary evil; professionals everywhere recognize the imperative of written documentation and communication. But there are times when paperwork becomes overwhelming and seems to overshadow the real priorities of the job.

To the meticulous reader, paperwork can become a tedious task. What's important gets buried among mountains of less relevant information. Precious time gets wasted just in the sorting, making the process particularly boring. Frustration builds when the task takes us away from the priorities and real joys of our work. The end result is stress.

It's My Livelihood; I'm Helpless
Changes in the healthcare delivery system, especially the advance of managed care, raise stress on two fronts. First, the corporatization of healthcare increases competition between providers, with the focus on which providers will do the most work for the least amount of money. Tenure and job security mean less and less as competition for jobs grows more and more intense. Coupled with continued projections of a physician glut, the stepped - up training of NPs and PAs serves as a constant reminder that midlevel providers face an uncertain future in which income and/or job security can be negatively affected.

Second, healthcare providers endure the added burden of responsibility for patients' well being in an environment where resources seem increasingly limited. The practitioner must always be alert to the life - prolonging diagnosis, no matter how routine the visit or how seemingly benign the complaint. As economics steadily creeps into the decision - making process, clinicians find themselves balancing what they think they should do against what they can justify to the "auditor."

These two stressors collide when management imposes new clinical mandates because they make business sense. Then, job performance, increased compensation, and career advancement no longer reflect clinical acumen. As bottom - line medicine defines clinical excellence and quality care, the frontline practitioner can't help but experience a mounting anxiety.

Most clinicians feel relatively helpless about these global changes in the healthcare delivery system. This loss of control intensifies the other uncertainties that come with dynamic change.

The Final Insult
"Be careful with the 'extras,"' says the office manager, who has no first - hand knowledge of patient care. Your years of advanced education and clinical training seem nullified by someone who believes you have no idea that you work for a business. It's hard not to interpret such comments as insulting and take personal affront to being told how to do your job by people who do not remotely understand patient care. You begin fantasizing about ... when your receptionist reminds you that it's 3:00 in the afternoon, you're only up to your 1:30 PM appointment, and there's still a waiting room full of patients.

COPING MECHANISMS
Understanding the source of real - life anxiety is the first step to conquering stress. The following strategies, which have helped millions of people cope successfully, have been specifically interpreted for healthcare professionals.

You Broke My Rule
Each of us needs to reexamine the rules we inherited. Look for specific incidents that "push your buttons." Is there a pattern that can lead you to a definable rule?

Start your stress reduction by assessing each "rule" and make certain that it really is important to you. As you go through the process, you'll find some rules to be appropriate and important; others, you'll discover, are someone else's "baggage" that you have jealously guarded without depth of thought.

For example, let us assume that being on time is a good rule worth keeping. First, make certain that you prioritize this rule with your other rules, including your rules for thorough and empathetic patient care. Next, plan for fulfillment of the rule.

In some practice settings, you have the option to determine the number of patients you will see in a day. The key to living with your rule is to set realistic goals. Track your own productivity so that you don't overbook. Plan for the emergencies and exceptions; leave a little room in the schedule for the unexpected.

Determining your own productivity is the exception rather than the norm. If, for example, management dictates that you see one patient every 15 minutes, you must come up with strategies to keep you on schedule without compromising patient care. Realize that you can spend 30 minutes with an acute case and still "average" 15 minutes per patient over the course of the day. Also, be sure to systematize all the paperwork and setup associated with each patient. Importantly, when you have to break your "on - time" rule and you fall behind schedule, make peace with both yourself and your patients. If you feel the need to explain the cause of your tardiness, keep your explanation brief and professional. A sincere apology can more than make up for the tardiness with most people; after all, we've all been late on occasion. Often this makes everyone a bit more pleasant to deal with and will relieve you of much of the pressure you're feeling.

If you continue to run late regularly, go back and readjust the schedule until you reach equilibrium. Very few of us feel stressed out over items that we are actively solving. If management does not allow you to customize your appointments, you have two main choices: 1) Accept their rule in place of your own, and relax; or 2) Find a new position with different management rules. Fighting to change your management is stressful at best, and futile and self - defeating at worst. If you turn your job into a crusade to "change the system," be prepared for even more stress.

Time - consuming, Boring, and Unimportant
Taking care of paperwork is a classic time - management dilemma. The secret is to break this task down into small, bite - sized pieces. One suggestion is to schedule 15 - minute intervals throughout the day to execute a few pieces of paperwork at a time. Does your schedule allow you to handle bits and pieces in between patients? If so, are you putting that time to good use?

Certain aspects of a clinician's paperwork can be delegated to support staff (provided you have support staff). For example, dictate progress notes into a recorder as soon as you've finished with the patient; support staff can transcribe the notes for your review. By all means, invest time to train someone to do such tasks for you.

Use today's technology to your best advantage. A laptop computer lets you review and correct transcribed progress notes during the bus ride home. Audio recordings from a recent continuing education meeting can provide badly needed credits during the drive to work. And a handy, pocket recorder lets you take notes for future review the moment they enter your head, without forcing you to rely on your memory.

The advances in computer technology that can increase a healthcare provider's productivity and reduce paperwork far exceed the limitations of this article. From e - mail, networking, and on - line consults to literature searches, drug interactions, and converting paper forms into electronic files, computers can and do make clinical practice easier. The payback for learning this technology and exploiting your options is a much more manageable schedule, with a lot less stress.

It's My Livelihood; I'm Helpless
Too often, people who feel trapped because they are tired magnify the negative and play down the positive. To control this form of stress, stand back mentally and try to gain some perspective. Divorce yourself from the minutia and focus on the big picture. You may just find that you have a wonderful life and a rewarding career. True, the situation is not perfect; nothing is. Odds are, though, that you've let the debits overshadow the credits.

Helplessness is a state of mind over which you do have some control. Too often, the pressures of the day leave no time to contemplate the choices you've made. It is, however, reassuring just to remember that you always have options.

Your clinical training provides many avenues for you to make money and live comfortably. Don't be afraid to explore your options (e.g., education, research, pharmaceutical representative, medical writer). Reexamine what you really need to maintain an acceptable standard of living, and clearly define your own priorities.

Those who prefer "the devil known" face the added burden of their own resistance to change. Taking on a new challenge with no guarantee of success, especially when you have responsibility for supporting a family, frequently freezes people into jobs that provide little satisfaction. Their stress grows as they struggle to gain control over events they are powerless to stop. Helplessness and fear rule their lives, as they wait and wonder when and how the next shoe will fall.

Climbing the corporate ladder often brings the disquieting realization that actual, absolute control is an illusion; there's always a higher authority no matter what your position in the organization. Few jobs completely eliminate accountability.

Influence over events is all any of us achieves in life. The secret to relieving stress in these situations is to blanket yourself with security devices that you can control.

For example, document, in writing, those directives that you believe compromise patient care. Request that such directives be made by memo; or, respond to such verbal directives with a memo outlining your concerns and asking for confirmation that you understood the directive correctly. Do not be confrontational - you simply want clarification.

At the very least, keep a diary of events as they unfold. Entries should be dated, with time noted; repeat actual dialogue as best you can remember. Such logs can be extremely empowering because they are proactive. Suddenly, you're no longer helpless; doing something gives you a sense of control.

Since your job is your livelihood, anything that threatens your livelihood threatens your security and consequently produces stress. Personal financial advisers recommend, as part of a lifetime strategy, that you keep between 6 months' and 1 year's salary readily available in savings. That's hard advice to follow when you're first starting out, but the goal can be achieved with sufficient discipline. Designate a certain portion of your salary for savings before discretionary spending. Maybe it's only $20 per pay check, and means you bring lunch from home instead of eating out every day. The payback in peace of mind more than makes up for the sacrifice required. As your savings grow, you'll find your sense of control reaching new heights, and your feelings of helplessness diminishing.

Finally, pick and choose your battles carefully. Do what is important to you, and let go of the rest.

The Final Insult
Most people have wanted to shout, "Would you like to do my job!?!" at someone occasionally. Many businesses have addressed this lack of understanding by cross - training employees in each other's jobs. Of course, that's not particularly feasible in the healthcare industry.

Try looking at the "insulting" office comments from the other person's perspective. Most human communication, in my experience, is either a "cry for help" or a "loving response." That said, try translating the call for belt - tightening as a cry for help. An angry response, which is another cry for help, transforms the opportunity to build an alliance into a confrontation that divides. Instead, respond with concern, as the member of a team whose teammates support one another. This opens the door for real communication and creates the opportunity for meaningful solutions.

BEATING STRESS FROM WITHIN
Stress can and will kill you because it robs you of your sense of self and causes you to lose sight of personal priorities. The marketplace is full of stress - reduction techniques that include everything from relaxation tapes to aroma therapy. Even the popular 10 - minute meditation break during the busy day significantly reduces stress. Each of these techniques carries one common thread: remove the overstimulation from the outside world and focus on yourself.

If you suffer from stress, I recommend you explore these techniques to find the ones that work for you. Just remember, such techniques treat the symptoms and not the underlying disorder. For that you have to dig deeper.

That is why the final word I have to offer you on stress is to identify the emotion you feel clearly, and decide what it means to you. Then ask yourself the following questions:

What else could I make this mean?

Is this really important enough for me to spend my time getting concerned over it?

If this is really important, can I influence it?

What do I need to do?

What is my plan?

What can I do right now?

Cindy, by the way, knows the true secret to stress management. She fights only the battles that really matter to her and that she knows she can influence. Then she lets the others go.

Published in the September - October 1997 issue of Clinician News.

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