An Ounce of Prevention

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Back from the Edge: Coping with Physician Stress

by David Hanscom, MD

^{Robin Diamond, JD, RN}

In this article, Dr. David Hanscom describes his personal journey toward managing stress. Dr. Hanscom, a board certified orthopedic surgeon specializing in complex spine problems, practices at Swedish Neuroscience Specialists in Seattle, Washington, and is a member of The Doctors Company.

—Robin Diamond, MSN, JD, RN; AHA Fellow–Patient Safety Leadership; Senior Vice President, Department of Patient Safety

Our culture expects doctors to be strong and stoic. Physicians do nothing to belie that impression—they rarely discuss their personal issues. It’s an unspoken rule that if you’re ever feeling stressed, you put your head down and persevere. That’s why I didn’t know that my close friend and fellow surgeon was on the edge. One afternoon last year, he left after assisting me in a complicated spine surgery. We shook hands and he said, “Nice case.” It came as an incredible shock when I heard that three hours later, he was dead from a self-inflicted gunshot to his head.

I later found out that my colleague was under enormous personal stress. His problems were complicated, but I know that much of his stress stemmed from his habit of constantly beating himself up. This led to uncontrollable anxiety, which had been building for several years. The tragedy is that he didn’t seek help earlier. He didn’t feel that he could.

My colleague’s story is not an isolated case. In fact, one in 16 physicians reported having contemplated suicide, according to a study published in the Archives of Surgery. This rate is higher than the general public (6.3 percent vs. 3.3 percent). Only 26 percent sought out help.¹ Out of my 80 medical school classmates, four killed themselves within three years of completing their training. Another dozen colleagues have committed suicide.

I can imagine how those doctors felt before deciding to end their lives. About 10 years ago, I was driving home one evening after a busy day at the clinic. I was agitated. I was in my mid-40s and was experiencing crippling anxiety on a daily basis. My anxiety had begun to rear its head 12 years earlier, and for the past year, I had struggled. I saw no way out. I was done.

That night, I weighed all of my options and decided that was it—once I pulled into the garage, I would close the door behind me and leave the car running. But at the final moment, I turned off the car. I thought of two classmates whose physician fathers had taken their own lives during my classmates’ teenage years. I knew how devastating it was, how hard it had been on them. I had a young son. I felt that I couldn’t abandon him and leave a legacy of death. If it weren’t for my family, I have no doubt that I would have left the motor running.

Burnout
Burnout contributes to the stress that can drive physicians to thoughts of suicide. About 40 percent of physicians experience burnout, according to the California Medical Board.² Doctors live with a combination of pressures that can result in burnout: suppressed anxiety, perfectionism, and massive amounts of stress.

Medical authorities have made some effort to limit stress on doctors. For example, there are now laws limiting residents’ work to 80 hours per week. Enforcement of these rules is spotty, though, and the older hierarchy feels that these guidelines are too lenient. Physicians face many stresses: running a business, angry patients, surgical complications, threat of litigation, partner problems, etc. As a surgeon, it’s not uncommon to operate for 10 or 12 hours and then go to the office for another four hours to catch up on paperwork.

Stress management skills are not part of the medical training process. No one provides physicians with the tools to assess their mental health. There are no preventative mental health resources, such as mental health professionals on staff; there’s no one to easily talk to about the stress. Any hint of mental distress causes the hospital to examine under a microscope the physician’s ability to practice.

Suppressed Anxiety
Physicians are conditioned to be really tough. From the first day we walk into the anatomy lab of medical school, it’s understood that we are essentially in boot camp. The intention is to quickly weed out those who cannot cut it. The ones who can suppress their anxiety are the ones who survive.

Early in my practice, I always thought I was in control. It didn’t matter what I encountered—angry patients, billing problems, even a malpractice suit—I remember thinking, “I can take it. Bring it on.” All physicians are used to being in control, especially when it comes to anxiety.

Anxiety cannot be suppressed forever. Research has shown that the more one tries not to think about something, the higher the chance it is thought about.³ Many physicians find themselves in a state of chronic anxiety. When this happens, surgeons may quit doing the bigger cases or stop doing surgery altogether. Addictions begin to surface. Other dysfunctional coping mechanisms, such as aggressive behavior toward staff and residents, are common. And then there is suicide.

Perfectionism
Doctors hold up perfectionism as one of the highest virtues of their profession. Most physicians would agree that “perfect” is the standard for our medical culture. It’s both implicitly and explicitly taught from the time they enter medical school. Unfortunately, many mentors react severely to their underlings when a given task is performed in a less-than-perfect manner.

But what does perfectionism really accomplish? Nothing. It’s a destructive trait. As doctors, our goal is 100 percent success for every patient. But that’s not humanly possible. If you torture yourself over every case that doesn’t turn out perfectly, you can’t do your job well. The energy burned up by judging yourself negatively is the energy you need to perform at the highest level.

Since there’s no such thing as perfection in the human experience, the difference between reality and expectation will determine the degree of your unhappiness. For many physicians, failure to meet the standard of perfection engenders growing anxiety, anger, and guilt that facilitate suicide.

Reprogramming
I was able to escape the perfectionist trap by using a technique known as neuro-cognitive reprogramming, which involves writing down your thoughts to create new, alternate neurological pathways. These pathways connect the thoughts with sight and feel. In David Burns’s book, Feeling Good,⁴  one of his tools is to write down negative thoughts and then categorize them. By using Burns’s writing methods and facing my anger, I was able to work myself out of the abyss. For me, it has been life altering.

There are other reprogramming methods. They include mindfulness/meditation, awareness, group dialogue, auditory methods, art, role playing, music, and many other techniques. Broken down, each follows a pattern of three parts: (1) awareness, (2) detachment, (3) reprogramming. Each person’s journey will be unique.

Going Forward
As a medical community, we must recognize that anxiety is not a dirty word and that it’s not a sign of weakness to admit that you have anxiety. Members of the medical community must engage in a dialogue about allowing doctors to speak openly about their stresses. Each of us is so good with our façade that we couldn’t imagine that the other physician is anything less than completely together. We are human, too, however, and we are suffering—badly. With an open dialogue, the medical community can start to heal its own members.

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