CONCEPTUAL, INSPIRATIONAL, EDUCATIONAL
PERSPECTIVES, GUIDANCE.
Stress is a word we cannot escape. It is a catch phrase of the twenty-first century. Everyone is talking about it, many claim to be experts in handling it, and many more deny that they even have it. It is routinely blamed for everything these days - from absenteeism at work to cardiovascular disease to apparent increase in mental illnesses to increase in crime rate. But what is it, and what are its effects?
We sometimes think of stress in terms of problems we face. This is, strictly speaking, not true. Stress is the reaction of the body and the mind to various problems or events that we face. It was Hans Selye (1907-1982) who first conceptualised stress as a non-specific reaction of the body to events or situations. Stressful events lead to neurotransmitter and hormone changes to cause a physical reaction in the body intended to help cope with the stressful event or situation. He first described this non-specific reaction in terms of a general adaptation syndrome, and described how this could lead to health issues if prolonged or repeated.
The events or situations that trigger the stress reaction are commonly known as stressors. An important thing to remember is that these stressors are not always ‘negative’ events. Even ‘positive’ events or situations such as getting a promotion, getting married, having a baby and even vacations (!!) can be stressors. There are scales available, such as the well-known Holmes and Rahe Social Readjustment Scale, that give a hierarchy of potential stressors and help predict how likely one is to have stress-related health issue or breakdown.
Although the body’s stress reaction is a non-specific one, the intensity of the reaction differs from person to person. For example, veteran soldiers and little children may have very different reactions to a bomb blast. The same event may be more stressful for one person than for another. These differences are largely based on how the person perceives the stressful event or situation, and how well he or she can cope. The mind thus powerfully influences the stress reaction.
The mind and body are not completely different entities with no relation to each other. They are part of the ‘whole person’ and are intimately related and interconnected. A simple example can help make this clearer. Imagine you are walking on a road, and you suddenly see a big snake. What would be your first reaction? Probably one of fear and terror. These are emotions in your ‘mind’. However, you will also immediately notice that you are sweating a lot more, your muscles are tight, your heart is racing and you are breathing fast. These are very real, measurable changes that are happening in your body. They are not symptoms of any ‘disease’, but are the normal reaction of the body triggered by the unpleasant emotions in the mind. Taken together, this mind-body response helps prepare you to handle the situation - either by running away or by killing the snake. This is an example of how anxiety can be adaptive. When this response is out of proportion to the trigger, or occurs in the absence of triggers, it can be considered an anxiety disorder.
Now consider the above example again, with a small difference. You are a naturalist that studies snakes, and you recognise this particular snake as not being poisonous. Would you have the same level of reaction? Probably not. This is an example to illustrate how one’s perception affects the response to a stressor.
It is no secret that medicine is one of the most stressful of professions. Doctors, nurses and other healthcare workers are always fighting battles that are challenging and often not completely winnable. Disease and distress, life and death, health and illness - decisions about these complex issues constantly have to be made in quick succession.
What about within the various specialties within the field? We commonly associate stress with certain fields. Surgeons and critical care physicians are constantly making difficult, quick decisions with immediate consequences. Anaesthetists hold the patient’s lives in their hands for prolonged periods of time. Ophthalmologists are dealing with very delicate structures that have immense value for the patients. Obstetricians have to balance the needs of mother and baby, both of whom are in their most vulnerable states under their care. Psychiatrists have to constantly deal with difficult, negative personal and family stories and face patients who are breaking down with stress. Pediatricians are dealing with little children, and nobody likes seeing little children suffer. Pathologists have the pressure of having to clinch the diagnosis so that their clinical colleagues can plan their management. And so on and so forth.
But what of Family Medicine? What is special about this field? Family physicians have several unique issues that add to their stress. First and foremost is the sheer breadth of knowledge and skills required for them to practice. Almost any kind of patient may walk through their clinic door, and they have to be able to recognise and diagnose it, and decide whether to manage it or appropriately refer it. The next patient could be a diabetic, a patient with a leg ulcer, a hypertensive, a lady with menstrual problems, a child with diarrhoea, an alcohol dependent with liver disease, a difficult pregnancy, a depressed patient with suicidal thoughts, or a patient with an infection in the ear.
Second, family physicians are expected to not only treat the patient, but also explore individual and family issues that may be relevant to the patient they are treating. Often, they may be treating more than one person in the family, and may have to handle complex family dynamics and conflicts as well.
Third, family physicians are often not given the status and respect they deserve. Not only are they not respected by their medical colleagues, who often value ‘specialisation’, but patients often view them as being a ‘junior’ or some kind of ‘lower level’ doctor than specialists. Happily, this situation is changing considerably nowadays. However, a lot more advocacy needs to be done.
One of the important principles in family medicine is a focus on ‘whole person medicine’. An important thing to remember is that ‘whole’ must truly be ‘whole’. The family physician must focus not only on the physical aspects of a patient, but also his psychological, spiritual and social needs as well. He may not always be able to intervene in all these domains, but he needs to explore them, and help address them with appropriate referrals or support systems.
Another aspect of ‘whole person medicine’ often neglected is that the physician himself needs to be ‘whole’ in order to truly help others become ‘whole.’ This is probably the most challenging principle of family medicine, because it involves looking after oneself. Doctors are conditioned from the beginning of their training to look after others and place the needs of others above their own. However, this can be dangerous if the doctor does not also place some attention on looking after his own health as well. This does not mean just a routine blood check up every year or a walk once a week. It involves looking after all domains of one’s own health - physical, psychological, spiritual and social. One of the key ingredients of this is to develop coping skills to deal with stress. Doctors are always advising patients about these, but rarely practice these themselves.
These strategies may appear very simple and superficial when we speak of them. However, they are neither simple nor superficial. Infact, they take quite a bit of effort to do, and are ineffective unless done regularly.
MD (Psychiatry)
Psychiatrist,
Department of Distance Education
Christian Medical College, Vellore
FAMILY MEDICINE & PRIMARY CARE
AFPI KERALA MIDZONE PUBLICATION
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