By Franz Wiesbauer, MD, MPH - 19th Jun 2018 - The Medmastery show

Intermittent de-stressing for doctors: what it is and why you should practice it.

mindfulness for doctors

Miwa Sado shouldn’t have died.

At 31, the journalist was rapidly climbing the ranks at Japan’s national broadcaster, NHK, and until a few months before she died, was the picture of perfect health. She had everything to live for and seemingly, nothing standing in her way. Yet, on July 25th, 2013, Sado was found dead in her Tokyo apartment, clutching onto the device that ultimately killed her: a mobile phone.

Logging 209 hours of overtime in the month preceding her death, Sado succumbed to what the Japanese call karoshi, or death from overwork. Her story, unfortunately, is not rare and happens often enough that the Japanese have even given it a name.

In many (if not most) cultures around the world, working overtime is considered to be virtuous; a mark that you are a hard worker and worthy of recognition.We’re conditioned, as humans, to respect those who work harder than us; sacrificing yourself for the greater good is, after all, a noble trait. This tendency is a relic of ancestry—in hunter-gatherer societies, the longer and harder you looked for food, the more likely you and your family or tribe were to survive.

But in a 21st century world, this perspective is changing.

In many western societies at least, the focus has shifted towards working smarter, not harder. With most of our tasks becoming automated, and an overwhelming body of literature exposing the harms of stress and overwork, the collective aspiration now is to live stress-free lives where family and leisure take precedence over work. We no longer value hard work; we value smart work. We want to work to live, not live to work.

This shift is driven by one very important factor: we’re sick of stress. The adrenalin and cortisol rushes might be fun when we’re young but as life wears on, the mental burnouts and illnesses that accompany chronic stress make for a miserable life.

But stress is unavoidable. We tell our patients to remove stress from their lives yet we are often stressed and overworked ourselves. Physicians have the highest depression and suicide rates above any other profession and that figure doesn’t look like it’s going down anytime soon. We play with life and death every single day and whether we like it or not, that’s always going to come with some element of stress. The culture of silence which leads to karoshi in Japan also exists within hospital environments around the world—we don’t tolerate weakness or fallibility amongst doctors and make it difficult for physicians to speak up when they’re struggling.

Since stress is unavoidable in the life of a physician and the weight of the system seems to be working against us, how do we mitigate the stress we endure so we don’t end up like Sado?

Locus of control

Steven Covey is often referred to as one of the godfathers of self-improvement. His famous books, The 7 Habits of Highly Effective People arguably spawned the modern-day personal development industry. Of all of his groundbreaking models around personal improvement, the circle of influence concept is likely one of his most powerful.

The concept describes our actions and concerns in binary terms: every concern we have falls into one of two categories—our Circle of Concern or Circle of Influence / Control.

Credit: David Rynick.

The circle of concern contains all problems and worries that we cannot control; things like the weather, the views of the people around us, the economy, and so forth. The circle of control contains the issues we can influence: our work, our personal progress, our attitudes towards different situations.

Proactive people focus on their circle of control; these people have an internal locus of control. They don’t waste time worrying about items outside of their control because they understand that this is time wasted. Reactive people live their lives worrying about things within their circle of concern; they have knee-jerk reactions to situations in their lives because they don’t take the time to choose their response. Reactive people have an external locus of control. They live alongside constant stress because they believe they are at the mercy of circumstance; they focus on what happens to them rather than what happens because of them.

The magnitude of stress you feel is dependant entirely upon your locus of control. When you live a reactive life, you’re always worried about events outside of your control so you’re always on the alert.

Stress, therefore, is a choice. It’s proportional to the size of your circle of concern and whether or not you have an internal or external locus of control. The less you focus on things outside of your control, the more headspace you have to focus on the circumstances you can influence. By building a life based around what you can control versus what you can’t, your levels of stress naturally subside, which in turn gives you more emotional control over how you react to situations. It’s a negative feedback cycle that works in your favor. Eventually, you begin to realize that regardless of the circumstance, there will always be some element within that situation that you have control over—even if that’s simply control over how much you let it stress you out.

Identifying your locus of control

How do you know if you have an external or an internal locus of control? The following exercise will help you determine whether you are predominantly operating within your circle of concern or your circle of influence.

  1. Draw a table with three columns. Write the following headings in each column: Problem, Solution, R / P (reactive / proactive)?
  2. Make a list of all the concerns, issues, and worries currently facing you in the Problems column.
  3. In the second column, write out all the solutions you feel are needed to resolve the first problem. Write these out in full sentences.
  4. STOP right here, don’t read any further before you’ve written down at least 3 problems and solutions (I know you're itching to continue reading but just trust me–don't. 

Now for the fun part. Go through each of the solutions listed and look carefully at the language you’ve used. A life lived in the circle of concern is dominated by passive language. Look for terms like if, when, and have (e.g., If I have more staff, when I have more free time, etc.) Any sentences like this should be marked with an R in the third column. Conversely, proactive language is focused on you; terms like I can, I will, and be (e.g., I can be more organized, I will delegate tasks better, etc.). Each of these get a P in the third column. Tally up your R’s and P’s. Which type of language do you tend towards?

This is by no means an exhaustive exercise but it gives you an indication as to your locus of control. If you find that you exhibit language aligned with an external locus of control, never fear: we are not born with our locus of control. We cultivate it.

Building an internal locus of control is as simple as deciding to do so and following up with the required work. That work involves being aware of how you generally react to situations and consciously choosing your response. The easiest way to cultivate that awareness is to engage in intermittent de-stressing; otherwise known as mindfulness.

Mindfulness is simply a term to describe the process of staying in the moment. Stress is a product of worrying about the past or the future so living in the present automatically precludes stress. There are many exercises you can do to maintain calmness but practising mindfulness underpins all of them.

It’s very simple. Whenever you’re faced with a stressful situation, focus your attention inwards and become aware of how you’re feeling. Don’t judge your feelings; simply observe them. Sit with them for a moment and then ask yourself this question: can I do anything about the situation I’m currently in? If the answer is yes, map out your plan to resolve it, and do it. If the answer is no, you now have a choice. You can choose to stress out over the current situation or you can make the choice to accept it and not let it bother you. This is much harder than it sounds but it works. The more you do this, the more this process becomes second nature to you and the easier it becomes.

Make a habit of intermittent de-stressing and build your mindfulness muscle. Whenever you feel the familiar feeling of worry creeping in, immediately follow the process above. Learn to live in day-tight compartments so that you leave no room in your life for fruitless worrying.

Got any tips for intermittent de-stressing throughout your day? Share them below!