On our way to a medical meeting a year ago, a friend of mine said, “Jim, I'm glad I'm retiring. I think we've reached the nadir of medical practice in the United States. It's impossible any longer to uphold the standards of William Osler, and it may not even be possible to live up to the Hippocratic Oath.”

I don't think my friend is alone in his thinking. These days, many family physicians are suffering from stress, and we need to keep it from getting the best of us.

Sources of stress

There's no evidence that family physicians endure more stress than others, such as air traffic controllers, whose occupations are associated with high levels of stress-related illness. But unquestionably, we can identify some stressors that affect physicians more than other professionals:

• The constantly changing nature of managed care;

• Increased litigation;

• Growing government intrusion into the practice of our profession;

• A new expectation that we contain costs and that we provide affordable, rather than ideal, services;

• The simultaneous and almost contradictory expectation that we stay up-to-date and always provide high-quality care;

• Escalating practice costs;

• Declining esteem in the eyes of the public.

We can lay some of the blame for the public's declining esteem of physicians at the door of managed care, but the changing health care system isn't our only problem. Patients and society as a whole are strongly ambivalent about physicians. We may be seen as invulnerable healers with “godlike decision-making powers” or as quacks out to make a buck — or anywhere in between. This ambivalence is not new, as we can see from a 1620 epigram by John Owen:

Our patients expect us to be available whenever they need us, to have time to listen to their concerns and to be in a good mood, no matter how exhausted we may be. We're supposed to be infallible in diagnosis and treatment and to be paragons of virtuous behavior in our communities. We may realize these expectations are unrealistic, but they cause considerable stress nonetheless.

In addition to the pressure from society and patients, much of a family physician's stress is self-induced because of the very qualities that make him or her good at the job. Family physicians are empathic, and empathy can lead to over-involvement. Physicians are conscientious and tend to overwork themselves; our “shadow” is self-doubt, accounting for the compulsion to read and attend courses. Most physicians are conflicted about the issues of dependence, as is best seen in how we make poor patients when we're sick ourselves. The need to be cared for is converted into caring for others.

Signs and symptoms

Evidence of stress is generally more obvious to others than to the individual. The evidence often reveals itself in the doctor's family, which becomes the repository of his or her signs of stress. Frequently, we ignore our families' emotional needs and seem to have no clear idea of what a mature relationship is all about. This has serious consequences: Although the divorce rate among physicians is lower than among other professionals with similar incomes, the misery in their marriages is actually greater.¹

How do you know whether you're getting into trouble from overwork and stress? Potentially dangerous signs and symptoms include these:

• Indecision about making diagnoses,

• Neglect of patients as evidenced by not going to the hospital or not returning phone calls,

• A harried lifestyle,

• Gradual withdrawal from friends and events you once enjoyed,

• Irritability with those close to you (generally your family and office staff are first to suffer),

• Alcoholism and drug abuse.

Prevention: self-care

If we take better care of ourselves, we can avoid many of the problems associated with our stressful lives. Over the years, I've learned from my patients who are physicians and from the spouses of physicians that these are the most important things we can do to prevent the worst effects of stress:

1. Maintain a sense of optimism. All of us possess at least a kernel of optimism, and we can take steps to cultivate it. One way to strengthen your optimism is to find optimistic role models. Think of Ronald Reagan. As president, he was nearly always cheerful, smiling, upbeat — and successful.

2. Work on your friendships. Family physicians need to spend time focusing on how to make other people feel at ease, how to be active listeners and how to be interesting. In our busy lives, we tend to neglect the friends we've had for many years. But great friendships are like great wines; the older they are, the better they get. The friendships we do develop require nurturing by forgiveness and by reaching out.

3. Focus on two special individuals in your life. Most women in America have a close female friend and a male friend, their husband or significant other. Men need bonds like these, as well. Special people in our lives aren't just friends; they're intimates. These individuals know our shadow. With them, we can let down our guard and show the less desirable sides of ourselves. These people, too, require special care and nurturing.

4. Plan for retirement. Most physicians seem to think they will be practicing medicine forever. (At least, they think that when they aren't yearning to get out of what medicine has become.) We need to think concretely about how we will spend our leisure years, and we need to take some leisure time before we retire. It's commonly accepted in psychiatric circles that school teachers are the most successful retirees because they have practiced retiring for several months every summer. Since physicians have very little experience with vacations, we tend to make rotten retirees.

5. Take care of the old equipment. We health care professionals need to look after our health. This means don't smoke, don't drink alcoholic beverages to excess, keep your weight within 20 percent of the values on the actuarial tables, exercise regularly, get seven hours of sleep a night, brush your teeth daily and eat three meals a day, including breakfast. Sure, you know it. Do you do it?

6. Keep a sense of humor. A sense of humor is one of the most important elements of a healthy life. There's no question that people who lack a sense of humor have great difficulty coping with the vicissitudes of everyday living. Try to keep your stressors in perspective.

7. Do something you like. Physicians are often trapped in what Richard H. Rahe has referred to as “joyless striving.” Joyless striving is one of the most stressful circumstances in which we can find ourselves. Physicians need to realize that we, too, can transfer our life's goals and wishes into other channels. If medicine isn't as fulfilling as it once was or doesn't meet the needs you expected it would, don't be afraid to explore the rest of the professional (and nonprofessional) world.

8. Be comfortable with assertiveness. This means not losing your temper but also standing up for your rights. It's a delicate balance but one we all must strike.

9. Believe you can change. Physicians frequently say to me, “I am too old to change” or “I'm too set in my ways to do anything about it.” This negative attitude belies the truth: Everyone can change at any age.

10. Get help if you need it. Physicians are very reluctant to take medical advice. We frequently get curbstone consultations; we don't take the advice we're given; and we sign out against medical advice five times more frequently than other patients. Physicians need to realize we are vulnerable just like other citizens and may need the help of counseling at times.

We're limited in what we can do about today's health care environment. But we can stand up against the winds of change by changing our outlooks, our lifestyles and ourselves.