The practice landscape is quickly changing. From health-care reform to electronic medical records to high expectations from patients and third-party payers, stress among physicians is at an all-time high. “The chaos that physicians are feeling comes from the rate at which change is occurring,” says Craig N. Piso, PhD, president of Piso and Associates, and a clinical assistant professor of psychiatry at the Commonwealth Medical College in Scranton, Pa. “It can be difficult to adjust to change. Even though many of these stressors are in the world of the imagination or assumption, it’s enough to get physicians really stressed out.”

He recommends staying focused on the fact that the jury is still out on most of the issues surrounding health-care reform. “Don’t make assumptions or believe the rumor mill,” Dr. Piso says. “Wait until the changes actually take place to become worried. However, be proactive. Take steps now to be frugal in your practice, assuming that threats could be real, but don’t torment yourself by believing it’s a done deal before it’s a done deal.”

These new stressors are compounded by the issues that physicians have always faced. “Taking care of people who are sick and scared can, in and of itself, be stressful,” says Matthew Goodman, MD, co-director of the University of Virginia School of Medicine’s Mindfulness Based Stress Reduction Program. “Additionally, in the past 10 or 15 years, there has been an increased focus on productivity, so there is more pressure to see more patients in a shorter period of time, and I think that just compounds the basic problem of having a job that can be inherently stressful. Additionally, there are high public expectations.”

Stress at work doesn’t just affect your work life. It can infiltrate all areas of your life. “When we become distressed and are not coping well, there is a tendency to become fearful or anxious and regressive—to become more preoccupied with ourselves and our state of insecurity. This will have a broad effect that will spill over both at work and in our personal lives,” Dr. Piso says. When people become stressed, they tend to become self-absorbed. Instead of focusing on patients or their relationships with family members and friends, they begin focusing on themselves. “While this is normal, it is extremely unhelpful for running a successful business or managing a successful life,” he adds.

Remain Focused on Others

To prevent self-absorption, Dr. Piso recommends maintaining a focus on a mission and on a purpose greater than oneself. “As physicians, that means taking care of patients, which is the best way to ensure business success,” he says. “Really treat them exceptionally well and wow them through both medical/surgical treatment and customer service. Do the same thing with staff, because you don’t succeed in business without your staff representing you and enabling you. The purpose that is greater than oneself is serving the mission of patient care, the organization that you are a part of, your staff and their families, and then trusting that, by being mission-focused, it comes back to you,” he says.

This helps in several ways. When you are thinking about others, you are at least temporarily not thinking about your own problems or worries. Additionally, if one of your worries is the future success of your practice, maintaining an outward focus can be good for business. “It is the most important business strategy,” Dr. Piso says. “Also, really empower your staff, who in turn take care of these patients and take care of you. It comes back to you many times over when they see that you are an unselfish leader. You are modeling the highest-level behavior that you would want from staff.”

Change your Mind-set

Another way to cope with change is to learn to embrace it, which can be difficult for some people. “This may be the most important thing,” Dr. Piso says. “Healthy, strong individuals, in general, become really adaptive and flexible. There are things people can do to develop emotional core strength. This allows them to gain better ability to make adjustments, to be adaptive and to be flexible. We know that if you have rigidity at a time when you are required to be flexible, you’re going to have your rough edges polished or beaten off of you. It can be rough going for those who do not embrace change. The ones who are going to thrive are the ones who say, ‘Bring it on!’

“Rejecting change just doesn’t fly,” he adds. He quotes the author Stephen Covey, “What we need in this world of permanent white water is something that does not change—a changeless core.” If you have core strength and you are solid and strong at the center, you can be open, adaptive and flexible when it comes to dealing with the changes occurring outside of you, Dr. Piso says.

Strategic Planning

While there are some things you can’t change, there are many things that remain within your control. Instead of worrying about the future, strategically plan a future course for your practice. “Say that in the next year, two years or three years, at a minimum, this is where I want to be in my practice,” Dr. Piso says. “Think about things like the number of providers you want to have, the provider mix, the types of services you will be offering, the geographic scope, and when and whether you want to add more partners. Those who have a strategic plan and answer some of those key questions are going to cope much better amidst the chaos and the changes coming down the pike than those who become reactive like a weather vane in a swirling wind. Be the wind. Determine your own direction. Have a plan. Be proactive. In the future, you might have to adjust and recalibrate, but at least you are polishing an existing plan as opposed to swirling in the wind because you have no plan.”

Self-Care and Wellness

Especially during times of turmoil and stress, it is important to focus on wellness.

While it is important to maintain an outward focus, make sure to take some time to focus on taking care of yourself. People who are stressed or anxious often don’t get enough sleep, which can make them more stressed and anxious. “If you focus on sleep, other things tend to normalize a bit, and you are able to cope better with the stressors of your day,” says Sara Taylor, MD, a family physician in Alberta, Canada, who is currently working on the Physician Wellness Anthology Project, which promotes physician wellness through sharing personal stories and ideas on dealing with stress. (

She also notes that eating well is important, even if surgeons feel like they don’t have time to eat a healthy lunch. She recommends incorporating it into your routine to bring a healthy lunch from home to keep you from making unhealthy choices during the day when there may not be time to search for healthy options.

Daily exercise is also important to keeping stress levels under control. “Many workplaces have brought in yoga instructors. This is fantastic and can make a big difference in your stress level,” says Dr. Taylor.  “Have a room in your practice with some exercise equipment, or try to get outside,” she says. She notes that there are even meditation phone apps that can be helpful.

Relaxation and creative outlets are also great stress-reducers. “Read, or just hang out with family,” she says. “My blog has allowed me to have a hobby and be creative. I think those things are really important, too. Surgeons may play an instrument or take up writing. Foster hobbies that channel your creativity.”

Separate Work and Home

Dr. Taylor recommends compartmentalizing work and not allowing it to filter into your home life. “Find a balance between where work ends and your home life begins,” she says. “Technology has made it more difficult to do that. Between computers and handheld devices, you could be doing work all of the time. Charts are electronic. Lab work comes electronically. You really have to separate the two things.”

Dr. Goodman agrees. “We now have the ability to be connected 24/7,” he says. “I recommend that physicians watch that when they are not working, because much of this connectivity is self-imposed. There are times when we are on-call, and we need to be on-call and connected, but there are times when we are on vacation and the culture should accept the fact that we are not checking e-mail and returning phone calls while on vacation. I think that doctors need to protect their own time and make sure that they take some time for themselves and disconnect from their devices.”

He adds that physicians need to make sure that they are not working to the exclusion of maintaining their relationships with their families and friends. He also recommends nurturing a spiritual connection. “This can include formal affiliation with a religion or just having a connection to something greater than yourself, whether it is through yoga, meditation or spending time in nature,” he says.

Dr. Taylor also cautions physicians against saying yes to too much. “Learn to say no. Being overwhelmed can cause stress and fatigue, which can lead to burnout,” she says.

She also recommends practicing gratitude by thinking of one thing every day to be grateful for. “I believe that gratitude can help you be happy in life. Focus on the good things in life, instead of the things that don’t go well,” she says.

She also advises surgeons to be mindful and present in the moment. When people are stressed and anxious, they may be so busy concentrating on what’s coming next that they miss out on what’s happening right in front of them. “When we try to multitask, we may think we are getting many things accomplished, but, in fact, our divided attention does not allow us to do any one thing really well,” she warns. “Mindfulness makes you stop and be present in the moment. Whether you are with your children or in an encounter with a patient, just stop and notice how much you are really paying attention. Are you truly in the moment and paying attention to what people are saying?”

Dr. Goodman recommends working to become more self-aware. Learn to monitor your own thoughts and feelings to know when you are becoming stressed, and then learn to calm yourself. “In order to effectively and compassionately care for other people, you have to care for yourself,” he says. “If you are burned out and stressed out, it is hard to be your best with patients, both technically and in your relationships. I was recently talking to a nursing colleague, and she told me that, in their guidelines, self-care is considered an ethical obligation. It is interesting to think of it that way, because when we think about self-care, we think it is self-indulgent, but if we don’t do self-care, we are at risk for burnout and poor practice, if not malpractice. People who are burned out and stressed are more likely to drop out of the profession all together, and we certainly see that happening with doctors leaving the medical profession at a time when we really need doctors. People might think that they are being good professionals by working themselves too hard, but in a sense they are really not.”  REVIEW