Stress is an unavoidable component of our working life. How we deal with it may have profound consequences for our job satisfaction, our health and the standard of care we are able to give our patients .
Any stressful event will elicit a characteristic physiological response consisting of autonomic stimulation and heightened arousal, which will then persist to some degree for the duration of the stressful stimulus. During an acutely stressful event, such as an intraoperative critical incident, this 'fight or flight' reaction may directly contribute to the resolution of the stressful event. On the other hand, because chronic occupational stresses such as poor working conditions or extended hours are seldom amenable to rapid resolution, the fight or flight reaction in these circumstances may be both inappropriate and ineffective.
Our ability to tolerate stress is the result of a complicated interaction of inconstant factors. These include our own personality and coping skills, our current levels of fatigue, distraction or frustration, our experience of previous stressors, the strength of our social or occupational support and, not least, the nature of the stressor itself. However, a fundamental component is our individual 'locus of control' . This term describes our belief in our ability to influence events around us, individuals who believe they have this ability having an 'internal' locus, in contrast to those with an 'external' locus who place more emphasis on the role of chance. Individuals with an internal locus of control tend to report less occupational stress than those without it .
Recent studies of occupational stress in nurses have demonstrated the complex relation between the perception of stress and the character of the individual. In a study comparing occupational stress between intensive care unit (ICU) nurses and non-ICU nurses, the ICU nurses found that their ICU nursing activities were less stressful than non-ICU nurses found their non-ICU nursing tasks to be . The authors concluded that ICU nurses had maximized their job satisfaction, and minimized their occupational stress, by selecting a speciality that offered them the high degree of personal autonomy and job complexity which they required for personal fulfilment. In a separate study, when ICU nurses were asked to specify the most stressful aspect of being an ICU patient they selected items relating to loss of personal control significantly more frequently than ICU patients did when given the same questionnaire . The association of a preference for working in a stressful environment, a strong need for personal autonomy and an internal locus of control has been described as 'Type A' behaviour . This rather loose term also includes characteristics such as self-confidence and a strong work commitment, a preference to work alone when under pressure and an urgent sense of time pressure.
Type A behaviour is observed more frequently in doctors than in other health professionals, and is associated with a high level of job satisfaction, a low perception of occupational stress and a low requirement for sick leave . Although the prevalence of Type A behaviour in different medical specialities has not been studied, it is likely that doctors who have chosen a speciality in which they usually work alone, and in an environment over which they can exert a high degree of personal control, might be expected to display marked Type A behaviour patterns. Many anaesthetists and intensivists will recognize this as a description of their own working practice.
If Type A behaviour offers a degree of protection against the consequences of choosing a profession with a high exposure to occupational stress , and if doctors in general, and anaesthetists in particular, display a high prevalence of this behaviour, is there any need to be concerned about our exposure to stress in the workplace?
The obverse to the high-achieving behaviour of the Type A individual is their tendency to suppress symptoms of fatigue, and sacrifice their own and their family's social needs, to their pursuit of a successful career . This is exemplified by the results of a survey of occupational stress in health professionals, which demonstrated that doctors made less use of coping strategies such as social support, and were less able to separate home and work, than almost any other group . It has even been suggested that health workers have a particular susceptibility to occupational stress because of the emotional stresses to which they are exposed , particularly if they have not been trained to deal with these aspects of their work .
Occupational stress is usually beyond the individual's control, and is therefore exactly the form of stress with which competitive, achievement-orientated Type A individuals are least able to deal . In the face of such stressors, individuals may adopt coping strategies such as denial or rationalization which, whilst providing apparent short-term relief, actually perpetuate the individual's exposure to the stressor. Furthermore, although decreasing the individual's emotional involvement in a stressful situation may be helpful in the short-term, in the face of continued exposure these coping mechanisms can lead to a growing sense of detachment and cynicism, impairing the health professional's ability to emphathize with their patient, and resulting in a progressive reduction in job satisfaction. If their home and work environment are already poorly separated, the emotional detachment is likely to extend into the individual's home life, and slowly erode the support it previously offered . In the long term, this will increase the doctor's vulnerability to prolonged stress and lead to social isolation, professional over-involvement, emotional exhaustion and 'burn out' . Finally, the sustained fight or flight response elicited by continued exposure to the stressor may itself present a significant threat to the doctor's own health, through an increased risk of cardiovascular or infectious disease, as well as depression, anxiety and excessive alcohol consumption [10-12].
Another, more recent, factor adds a potent source of stress to this fragile structure. The protective effect of an internal locus of control on the perception of occupational stress is diminished if the individual feels they have lost control of the stressor. The recent organizational changes to the delivery of health care in many developed countries, with the consequent reduction in doctors' autonomy, poses exactly this risk. A recent study has confirmed an increase in the level of occupational stress, and a fall in morale, amongst doctors as a consequence of these changes .
These changes illustrate the challenge that is facing the profession. As doctors, we have chosen to work in a highly competitive, achievement-orientated environment. As anaesthetists and intensivists, we have selected a speciality in which our high degree of personal autonomy, and our control over our environment, contribute to our job satisfaction. Yet, as individuals, we are faced with a growing burden of occupational stressors that fall outside our control, and with which we are poorly equipped to deal. Since we are unlikely to be able to reduce our exposure to these stresses significantly, we should take steps to improve our ability to deal with them.
The first of these steps is to acknowledge our exposure to stresses beyond our control. The observations on doctors' behaviour through the centuries suggest that we are not good at conceding our own vulnerability and that, as care givers, we make poor recipients. This should not be a point of pride.
Second, we need to accept that not only are we probably not as good at dealing with these stresses as we might like to believe, but also that they may compromise both our health and the health and happiness of our families.
Finally, we have to equip the next generation of doctors with the skills they will need to meet the roles they will encounter in the course of their careers. This does not simply mean training doctors to deal with identifiable stresses such as starting a new job , comforting the bereaved  or managing the department , although this is important. We also need to develop a working environment in which we have the skills to support our juniors and the expectation that our colleagues will support us. Clearly this cannot be imposed by management directive. Rather it is the responsibility of us all to learn how to provide support to our colleagues, and to encourage them to support us.
Stress, like mortality, involves us all, and denial is no cure.
C. E. Granger
M. P. Shelly
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