Authors: Karishma Patel Bhangare, M.D. et al
ASA Monitor 12 2018, Vol.82, 8-10.
“Beep, beep, beep.” The alarm sounds at 5:15 a.m. You shower, get ready, grab a packed lunch and run to the car. It better not be later than 5:45 a.m., otherwise you will not make it to the hospital in time. Before turning on the car, you make sure you have everything needed for the day. Suction, oxygen, airway … oh wait, wrong checklist. You drive to the hospital, quickly change into scrubs, methodically organize your room and introduce yourself to the first patient. Maybe the day involves supervising three O.R.s, rounding in the ICU, seeing patients in the pain clinic, carrying the code pager, assessing risk during perioperative visits or performing various regional techniques throughout the hospital. When the day is over, you sit down, read about the cases for the next day and refresh your knowledge on anesthetic |implications of a disease process. Then you are off to the gym, dinner with family and, finally, bedtime.
What Is Coping?
Coping is quintessential to navigating an anesthesiologist’s day. Psychologist Dr. Charles Carver explains coping as a response to primary and secondary appraisals.1 Primary appraisal is “the process of perceiving a threat to oneself.” Secondary appraisal is the “process of bringing to mind a potential response to the threat. Coping is the process of executing that response.”1 It is impossible, in the course of a brief article, to effectively teach healthy coping. In this article, we aim to raise your internal awareness of the breadth of possible responses to stress so that you can more mindfully approach your own response when encountering daily challenges.
There are two modes of coping. Problem-focused coping seeks to alter the source of stress and is generally employed when something constructive can be done.1 Emotion-focused coping seeks to manage the distress associated by the situation and is employed when the stressor is something that must be endured.1
As an illustration, suppose that a wrong dose of antibiotic was given to a patient, resulting in acute kidney injury. On many levels, and for many reasons beyond the scope of this article, medical errors are particularly stressful for the anesthesiologist. There are several ways to cope with this situation, some more constructive and healthy than others (Figure 1). For instance, the provider may exhibit active coping by consulting nephrology, administering I.V. hydration and organizing a family meeting. The anesthesiologist may ask a colleague what they did after a drug dose error as a form of seeking social support for instrumental reasons. Conversely, they may engage in a manner of disengagement in order to mentally dissociate from the event (e.g., excessive use of alcohol or drugs).
Why We Need to Cope
Regardless of the coping mechanism utilized, coping is intimately related to burnout, as coping can be adaptive and engaging, or maladaptive and disengaging. Burnout is defined as “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration”2 and is characterized by emotional exhaustion, depersonalization and a sense of a lack of personal accomplishment.3 In other words, while burnout is the potential consequence of unmitigated prolonged stress, coping is what someone does in response to that stress.
When querying those coping with the aftermath of an adverse medical event, Scott et al. demonstrated a wide range of “normal” psychological and physical symptoms,4 highlighting the variety of responses in the wake of negative events. Several studies have reported burnout in medical training as worsening global mental health, depression, anxiety and substance abuse rates. Staggeringly, suicidal ideations may be prevalent in as many as 7.8 percent of students during medical school.5 Moreover, coping may lessen what Scott et al. call the “second victim phenomenon,”6 which occurs when health care providers involved in an adverse patient event themselves become traumatized. Burnout also affects physical health. A 2000 study in Finland showed positive correlation between the severity of burnout and physical ailments such as cardiovascular disease and musculoskeletal disorders.7
Shanafelt et al. state that “engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work,”8 which can in themselves be categorized as positive coping mechanisms.
How to Cope
Option 1: Letting Go (Disengaging)
After continuous emergency cases overnight, a child with acute appendicitis is depersonalized to “the appy in O.R. 7” and sarcasm may become a means of detachment from a sense of loss of control. One may forego proactive resilience-building activities out of a sense of survival and succumb to less healthy methods of maladaptive coping. Then, with additional stressors added, one eventually may retreat to solitude. This is the face of disengagement – of letting go.
In a 2013 article in The Journal of Graduate Medical Education, the authors found that residents who employed denial, humor or disengagement had higher emotional exhaustion and depersonalization scores.9 Self-blame was associated with higher emotional exhaustion; and disengagement and venting were negatively correlated with a sense of personal accomplishment.9
As unrelenting waves of stressors roll in, it can be easy to let go and disengage.
There are two modes of coping. Problem-focused coping seeks to alter the source of stress and is generally employed when something constructive can be done. Emotion-focused coping seeks to manage the distress associated by the situation and is employed when the stressor is something that must be endured.
Option 2: Getting a Grip (Engaging)
Instead of letting go (disengaging), get a grip (engage)!
The last stage in recovery after a negative event is “moving on.”7 Moving on can mean dropping out, surviving or thriving. Changing professional roles is an example of “dropping out,” and “surviving” occurs when one continues to perform but is disengaged and often plagued by the inciting event. Thriving is the most favorable outcome wherein providers have gained insight from the situation and use it to better themselves and their practices.7
Focus mindfully at the one task at hand and try to avoid the trap of attempting multitasking. A study published in 2001 found subjects’ response times were longer during alternating tasks than repetitive tasks.10 Take a mindful breath between challenging tasks. Find solutions to simple problems such as adding an extra computer screen for easier documentation. Find a way to work less on tasks that are uninspiring and more on projects that uplift, such as a new initiative to improve outcomes.
Final Thoughts
As human beings, if we are breathing and facing stressors, we are, by definition, coping. Regardless of the coping mechanism utilized, get a grip, because our patients are also coping. Through the roller coaster of diagnosis and treatment and their own attempts at healthy coping, our patients rely on us to be their strongest advocates. Instead of disengaging (letting go), we need to actively engage in the art of medicine through all the stressors, twists, turns and roadblocks. Mindfully focusing on healthy coping will give us our best chance of being the doctors our patients deserve, the people our families need and living our most satisfied life.
References:
1. Carver CS, Scheier MF, Weintraub JK . Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol. 1989; 56(2):267-283.
2. Burnout. In: Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2004.
3. Maslach C, Jackson SE, Leiter MP . Maslach Burnout Inventory. Palo Alto, CA: Consulting Psychologists Press; 1986.
4. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW . The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330.
5. Dyrbye LN, Thomas MR, Shanafelt TD . Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354-373.
Scott SD, McCoig MM . Care at the point of impact: insights into the second-victim experience. J Healthc Risk Manag. 2016;35(4):6-13.
6. Honkonen T, Ahola K, Pertovaara M, et al. The association between burnout and physical illness in the general population – results from the Finnish Health 2000 Study. J Psychosom Res. 2006;61(1):59-66.
7. Shanafelt TD, Noseworthy JH . Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
Doolittle BR, Windish DM, Seelig CB . Burnout, coping, and spirituality among internal medicine resident physicians. J Grad Med Educ. 2013;5(2):257-261.
8. Rubinstein JS, Meyer DE, Evans JE . Executive control of cognitive processes in task switching. J Exp Psychol Hum Percept Perform. 2001;27(4):763-797.
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