February 1982 III/6PHYSICIANS AND STRESS IN THE 21st CENTURY
I. This week another scholarly article appeared in a national medical journal depicting the stresses which occur in the life of physicians and the inadequate manner in which many physicians cope with stress. The author, Jack McCue, MD, believes that:
"The stresses in medical practice result from one or more of the following situations peculiar to medicine: working with intensely emotional aspects of life governed by strong cultural code for behavior, e.g., suffering, fear, sexuality and death; inadequate training for fundamental professional tasks, e.g., handling 'problem' patients; and demands from society or patients that cannot be reasonably met, e.g., the need for certainty when current medical knowledge allows only approximation." (1)
After analyzing these stress factors, McCue offers a resume of the effects of stress on physicians:
"It is certain that physicians who harm themselves also directly or indirectly harm their patients. Ample evidence indicates that physician impairment is common. The suicide rate of physicians is two to three times that of the general population. Alcoholism is at least as prevalent among physicians as in the general population, and under-reporting of physician-alcoholics is likely. Drug addiction may be 30-100 times more common among physicians than in the general population, a controlled study shows that heavy drug use, including use of alcohol, was 1.6 times more frequent among doctors than in a comparable group of non-physicians. Physicians are likely to have 10 or more visits to a psychiatrist than are controls."
(Note: While suicide, alcoholism and drug addiction indicate a poor reaction to stress, I do not think that visits to a psychiatrist should be used as an indicator of same. Everyone encounters stress; impairment occurs because one copes poorly with stress. But seeking the help of a psychiatrist can be a very effective way to cope with stress.)
McCue's article is remarkable, but not because it contains new information concerning physician impairment, nor because it offers any new or different solutions. Several other articles have appeared in the last three years which present similar statistics and scenarios~and which offer similar solutions. All these articles emphasize two things: (1) the problems that become acute in later life for physicians are seminally present in medical school and residency programs; (2) very little is being done in medical schools and residency programs to help young physicians prepare competently for the stresses they will encounter throughout their practice. McCue's article is remarkable then because he joins others who cite the same serious problems and to date very little has been done in medical schools to prepare people for these problems.
II. What does all this have to do with ethics? Well, ethics is concerned not with solving problems but more importantly with ordering life. Thus, the ethical physician would seek to avoid impairment, rather than be involved in the ethical issues that surround incipient or developing impairment. How would he or she seek to avoid ineffective coping with the stresses that are inevitably encountered? Briefly, the person would spend time pondering three things: first, what objectives should I have and which are more important; second, what are my motivations for being a physician, realizing that these are often subconscious and must be surfaced through reflection; third, what are my assets and limitations? To discern these things, any person needs the help of others, and the responses will change over time; hence, there must be a periodic reflection upon these questions. If a person, whether physician or not, does not engage in such self-renewal, he or she will get in a rut, find life very frustrating and eventually suffer burn-out in one form or another.
What has been said about the ethical individual who wishes to integrate his life and cope with the stress that each person must expect to encounter is true also of institutions. That is, the persons who make up any institution must come together periodically, reflect upon their objectives, motivations, strengths and weaknesses. Otherwise, the institution will get in a rut and suffer burn-out. How often do medical schools -- administration, faculty and students in MD and residency programs -- engage in such reflection? One of the great breakthroughs in the history of medical education occurred when the Flexner Report was written and implemented in the early 20th century. Is it time for another effort to assess medical education in view of the changing times, the intense stresses that occur, and the needs of patients to be cared for by competent physicians?
III. In order to be concrete, let me suggest that members of the learning community known as St. Louis University Medical School take the time in the near future to reflect upon their objectives, their motivations, and their strengths and weaknesses. Are the objectives listed in the 1981-83 Bulletin for the St. Louis University School of Medicine still valid? What does it mean to have a medical school at a university which professes to be in the Judeo-Christian tradition? Are students prepared to handle the stress of the future as well as the science of the future? For the most part, there are no "right and wrong" answers to these questions. But in taking time to reflect, an ethical identity will be developed, a sense of purpose will grow, and a much clearer vision of what means may be employed to obtain the desired objectives will emerge.
When suggesting our need to reflect as a learning community, I am aware that several beneficial changes have occurred in the last three years in curriculum, student-counseling service, examination schedules and class hours. But I wonder if these changes are sufficient and radical enough to effect the type of renewal which is needed to prepare competent physicians for the 21st century; physicians who will not only be prepared to learn and apply the new technology and scientific information in accord with the ethical ideals of the profession, but who will also be able to cope with the increased stress that will occur in their lives.
Kevin O'Rourke, OP
Footnote 1. "The Effects of Stress on Physicians and Their Medical Practice," NEJM, V.306, n.8; 2/25/82; p.458-468.
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