Stress is an everyday part of life. Stress is even more prevalent for emergency medicine residents during COVID.
Many of us are working harder than ever, putting our health at risk for individuals who, many times, seem to not care about our wellbeing. It makes sense that stress can lead to suicide, and the data support this fact. Physician suicide was already double the national average pre-COVID. Before social isolation, before PPE fatigue, before our jobs became even harder.
One of the biggest problems with stress is that we are so used to it, we can be blissfully unaware of it.
Am I Stressed?
There are several well-known stress scales, with one of the most widely used being the Perceived Stress Scale. This scale asks you to think back over the past month and answer 10 questions in terms ranging from 0 (never) to 4 (very often). The study also provides a table with averages for gender, age, and race. That is all well and good, but what about day-to-day? Are we supposed to answer these 10 questions every day? No, actually the data shows its validity decreases after 1-2 months of use. We do not need a fancy scale to figure out if we are stressed. I am sure if you think back you can begin to pinpoint some things you do when you are stressed. Friends and family can likely help if you are struggling to identify your "stress tells" or coping mechanisms. We need to be evaluating our stress levels frequently so we can intervene BEFORE we spiral. I have been guilty of that spiral, and I can assure you it is much easier to climb out before you end up at the bottom.
I'm sharing several markers of increased stress for me. For context: I am a chief resident at UF Health in Gainesville, Florida. I own a house and have 2 floofy puppers named Moose and Libby. I also have 9 chickens and a garden.
Already sounds stressful, right?
My personal stress scale:
- Can I not sleep because my mind will not shut off (not lack of time for sleep)?
- Am I eating my feelings more than normal?
- Have I yelled at my dogs for stupid things?
- Am I shutting myself off from friends and family?
- Have I yelled at said friends and family for stupid things?
- Am I crying at TV commercials or shows (ASPCA commercials do not count)?
- Am I letting things that are important to me slide?
- How long has it been since I gathered eggs from my chickens or checked on my garden?
- How long has it been since I actually cooked?
- Do I feel stressed?
If you notice, "Do I feel stressed?" is last. If I truly feel stressed, I am way down the proverbial rabbit hole. Most folks, especially ED residents, have a high tolerance for stress and for us to FEEL stressed takes a lot. If I answer "yes" to a couple of questions, I need to work on my stress level. If I yell at my dogs, that is a wakeup call; I need to do something. If I answer "yes" to almost half the questions, I know I need to reach out to someone for help.
I encourage you to make your own list. It does not have to be 10 things and you do not have to publish it, just write it down for your reference.
OK, so I AM stressed. Now what?
Now that we recognize our own personal signs of stress, what do we do about said stress? First, we need to realize how we are currently coping with stress. If you notice, in my stress scale above there are several unhealthy coping mechanisms. Overeating, withdrawing, angry outbursts, etc. You may find a similar trend in your list.
There are 2 broad categories for dealing with individual stressors: change the circumstances or change your response. If you can, avoid the circumstance causing your stress. This may work for some stresses, but it sure will not work for COVID. Are perfectionistic tendencies stressing you out? Channel your inner ice princess and let it go (ie, change your response).
Changing the circumstance can be any number of things. If COVID PPE is stressing you out, reframe how you think about it. Instead of it being another burden and time sink on an already busy shift, think of it as a way to protect yourself, friends, and family. If you are competitive, make a game out of safely donning and doffing. Alternatively, you can channel that stress and advocate for change! Your changes could lead to the betterment of many and reduce the inherent stressors of your institution. Small changes can make a big difference on a busy shift. If big changes need to be made, enlist faculty, and spearhead the change you want to see.
Changing your response can be much harder. Many of us have honed our stress response over years of high-intensity stress. We survive on stress, caffeine, and alcohol, dang it! Express your feelings in a CONSTRUCTIVE manner. Communicate your needs. If need be, insert a filter between your brain and mouth to catch the angry outburst and snide remarks. Keep those in your cartoon character bubble over your head. When we snap at others, they can become even more stressed. Then the stress can feed off each other and turn into a big, ugly monster.
The above works with individual stresses, but our lives have a double handful of stressors on a good day. Then what? Well that depends on what you find relaxing. Research abounds on the subject. van der Zwan, et al., determined physical activity, mindfulness meditation, and heart rate variability biofeedback all reduced perceived stress with no statistical difference between the groups appreciated. Abbott, et al., found that artistic tasks lead to greater stress reduction than tasks aimed at stress reduction that are not artistic in nature.
These 2 articles offer 4 broad stress reduction techniques. To me, this means pick something YOU find relaxing. Art may stress you out. For me, just the thought of physical activity outside of walking my dogs after a busy shift is stressful, while other folks like to sweat the stress out. The point is to find what works for you at any given time.
I have found several things that I typically find to be stress reducers: playing with my floofs (especially their tennis ball launcher), cooking (cheesecake, yum!), working in my garden, and hanging out with my friends (although COVID has put a damper on that.) The decreased ability to meet with friends and loved ones is hard on most people. Give video chatting a try. There are some web-based games that will work over video chatting. Humor is considered a healthy coping mechanism, which is a good thing seeing as most ED staff have a dark sense of humor. Try yoga or meditation or any other studied stress-relieving techniques. If you are able, schedule some “me time.” Even 5 minutes can help. Try a massage if the idea of a stranger touching you does not freak you out. The list is endless, but it may take some time and practice for you to figure out what is most relaxing for you.
If you need help, please ask! Ask your co-residents, your attendings, your program leadership, your family, your non-work friends. Your non-ED friends and family will not understand as well, no matter how hard they try, but they can be surprisingly good listeners.
- Stress is ever-present. We need to be aware of our stress levels and our coping mechanisms.
- Individual stressors can be handled in different ways, and you must also develop a strategy for coping with cumulative stress.
- Ask for help. And if you see somebody struggling, reach out and try to help.
- Rosiek A, Rosiek-Kryszewska A, Lekowski L, et al. Chronic Stress and Suicidal Thinking Among Medical Students. Int J Environ Res Public Health. 2016;13(2):212.
- Anderson P. Physicians experience highest suicide rate of any profession. Medscape.com. Published May 7, 2018. Accessed July 28, 2020.
- Cohen S. Am I Burned Out? PERCEIVED STRESS SCALE. University of Colorado Anschutz Medical Campus Department of Anesthesiology. Accessed July 28, 2020.
- Robinson L, Smith M, Segal R. Stress management: How to reduce, prevent, and cope with stress. BrainLine. Published June 15, 2011. Accessed July 28, 2020.
- Robinson L, Smith M, Segal R. Stress Management. HelpGuide.org. Accessed July 28, 2020. Updated September 2020.
- Esi van der Zwan J, de Vente W, Huizink AC, Bogels SM, de Bruin EI. Physical Activity, Mindfulness Meditation, or Heart Rate Variability Biofeedback for Stress Reduction: A Randomized Controlled Trial. Appl Psychophysiol Biofeedback. 2015;40(4):257-268.
- Abbott KA, Shanahan MJ, Neufeld RWJ. Artistic Tasks Outperform Nonartistic Tasks for Stress Reduction. Art Therapy. 2013;30(2):71-78.