1. Stress Survival Strategies for Health Care Professionals and Patients Victor S. Sierpina, MD Nicholson Professor of Integrative Medicine Department of Family Medicine UTMB

3. What is stress? Stress is a non-specific reaction of an organism to a demand placed on it Stress is a non-specific reaction of an organism to a demand placed on it Eustress vs. distress Eustress vs. distress

4. What is stress? Stress can be defined as a state one experiences when there is a mismatch between perceived demands and perceived ability to cope. It is the balance between how we view the demands and how we think we can cope with them that determines whether we feels stressed or otherwise.

5. Risks of stress in Medicine Burnout Burnout Early retirement, job/career change Early retirement, job/career change Family relations issues Family relations issues Drug/substance abuse Drug/substance abuse “Compassion fatigue” “Compassion fatigue” Absenteeism/presenteeism Absenteeism/presenteeism

6. Some intrinsic stressors in Medicine Staffing Staffing Scheduling Scheduling Time pressures Time pressures Diagnostic challenges Diagnostic challenges Malpractice Malpractice Sleep deprivation and shift work Sleep deprivation and shift work PTSD PTSD Role ambiguity among residents Role ambiguity among residents Depressed immunity Depressed immunity

8. Patient related stressors Communication issues with patients and their families, verbal abuse Communication issues with patients and their families, verbal abuse Violence Violence Exposure to infection: hepatitis, AIDS, SARS, MRSA, DRE, other “bug du jour” Exposure to infection: hepatitis, AIDS, SARS, MRSA, DRE, other “bug du jour” Drug seekers Drug seekers Social, financial problems of patients Social, financial problems of patients

10. Central Nervous System

11. Central Nervous System hypothalamus P

12. Central Nervous System hypothalamus P Grand Central Station in the conversion of psychological stress to physiological function C

13. Central Nervous System hypothalamus central chemical messengers P P Grand Central Station in the conversion of psychological stress to physiological function C

14. Central Nervous System hypothalamus central chemical messengers P P Grand Central Station in the conversion of psychological stress to physiological function norepinephrine epinephrine corticotropin releasing hormone Ex C

15. Autonomic Nervous System

16. Autonomic Nervous System sympathetic nervous system (SNS) P

17. Autonomic Nervous System sympathetic nervous system (SNS) PP parasympathetic nervous system (SNS)

18. Autonomic Nervous System sympathetic nervous system (SNS) PP part of the “ergotropic system” (ES) C parasympathetic nervous system (SNS)

19. Autonomic Nervous System sympathetic nervous system (SNS) PP part of the “ergotropic system” (ES) C parasympathetic nervous system (SNS) prepares for action via arousal increase in skeletal muscle tone release of catabolic hormone products L

20. Autonomic Nervous System sympathetic nervous system (SNS) PP part of the “ergotropic system” (ES) C parasympathetic nervous system (SNS) part of the “trophotropic system” (ES) C prepares for action via arousal increase in skeletal muscle tone release of catabolic hormone products L

21. Autonomic Nervous System sympathetic nervous system (SNS) PP part of the “ergotropic system” (ES) C parasympathetic nervous system (SNS) part of the “trophotropic system” (ES) C prepares for action via arousal increase in skeletal muscle tone release of catabolic hormone products promotes withdrawal and conservation of energy decrease in skeletal muscle tone release of anabolic hormones L L

22. Styles of Coping (Lazarus, 1977) Direct action: Direct action: actions to alter, master, or flee stressor Palliation: Palliation: when direct action is not possible – ego defenses: – ego defenses: denial, rationalization – medications. – medications to reduce anxiety, BP, etc... – relaxation exercises/meditation – cognitive exercises/restructure thoughts – physical exercises/deep breathing

24. Organizational responses to stress Debriefing after traumatic events, psychological support Debriefing after traumatic events, psychological support Scheduling changes Scheduling changes Improved work conditions Improved work conditions Board certification in ER Board certification in ER Direct social support to nurses Direct social support to nurses

25. What Can Be Done About Stress? Biological interventions Biological interventions Psychological interventions Psychological interventions Social interventions Social interventions

27. Biological Interventions Exercise Exercise Improved nutrition Improved nutrition Proper sleep Proper sleep Relaxation techniques Relaxation techniques – progressive relaxation – self hypnosis – meditation Medications Medications

28. Psychological Interventions Coping skills training Coping skills training Identifying and preparing for stressful events Identifying and preparing for stressful events Evaluating cognitions and expectations Evaluating cognitions and expectations Assistance in stopping unhealthy behaviors Assistance in stopping unhealthy behaviors – smoking cessation – weight control – drug and alcohol treatment

29. Social Interventions Identifying and implementing social supports Identifying and implementing social supports Social skills training Social skills training Family and group psychotherapies Family and group psychotherapies

31. How do you unwind? Scream Scream Get sick Get sick Get drunk Get drunk Go to sleep Go to sleep

33. Or do you…. Laugh Laugh Work on a hobby Work on a hobby Play sports Play sports Meditate Meditate

34. All Effective Stress Management Programs Recommend Some or All of the Following Exercise Exercise Mind-body approaches Mind-body approaches Time management (prioritizing) Time management (prioritizing)

35. Personal/social stress resilience approaches found useful in studies for Emergency Dept. personnel Music listening and music making Music listening and music making Self reflection Self reflection Spiritual well- being, prayer, religious practice Spiritual well- being, prayer, religious practice Massage Massage Essential oils Essential oils Cognitive behavioral strategies Cognitive behavioral strategies Biofeedback Humor Mindfulness based stress reduction Psychodrama Imagery Relaxation therapies

37. Some Simple Techniques Deep breathing Deep breathing Progressive Muscle relaxation Progressive Muscle relaxation Music Music Meditation Meditation