Stress from Work, Personal Stress from Work, Personal and Family Life:and Family Life:

Perspectives of a Family PhysicianPerspectives of a Family Physician

Mark J. Yaffe, MDCM, MClSc, CCFP, FCFPMark J. Yaffe, MDCM, MClSc, CCFP, FCFP

Associate Professor of Family Medicine,Associate Professor of Family Medicine, McGill University and St. Mary’s Hospital CentreMcGill University and St. Mary’s Hospital Centre

DisclosureDisclosure Someone in this room likely authorizes that part of Someone in this room likely authorizes that part of

my income that comes from McGillmy income that comes from McGill

Longstanding clinical and research interests in Longstanding clinical and research interests in today’s topictoday’s topic

Some McGill employees in my practiceSome McGill employees in my practice

Up to Up to ½ o½ of my professional time has been spent as f my professional time has been spent as a manager for educational or health care delivery a manager for educational or health care delivery issuesissues

Many years of trying to juggle home life, Many years of trying to juggle home life,

professional life, & family caregiver professional life, & family caregiver responsibilities for 3 family members with serious responsibilities for 3 family members with serious chronic illness.chronic illness.

Overview of PresentationOverview of Presentation

(1)(1) Why is a FP interested in this topic and Why is a FP interested in this topic and from what perspective? from what perspective?

(2)(2) Look at examples of competing needs and Look at examples of competing needs and some life stressorssome life stressors

(3)(3) Stressors I have heard from some McGill Stressors I have heard from some McGill staff?staff?

(4)(4) Discuss signs & symptoms of stressDiscuss signs & symptoms of stress(5)(5) What is “well aging”?What is “well aging”?(6)(6) What is chronic disease , & the role it What is chronic disease , & the role it

plays in our lives?plays in our lives?(7)(7) Family Caregiving as a major stressorFamily Caregiving as a major stressor(8)(8) Opportunities for changeOpportunities for change

What is a Family Doctor ? What is a Family Doctor ? ** GeneralistGeneralist Cares for both sexesCares for both sexes All agesAll ages Holistic careHolistic care Aware of and responds to biological, Aware of and responds to biological,

psychological, social, ethical, & psychological, social, ethical, & spiritual needs of patientsspiritual needs of patients

Has a specific diagnostic processHas a specific diagnostic process

*optimal*optimal

Developmental TasksDevelopmental Tasks

Life span (life cycle) literature talks Life span (life cycle) literature talks of predictable challenges in personal of predictable challenges in personal development, relationships , & jobs development, relationships , & jobs that each of us must face—some that each of us must face—some handled successfully, some less sohandled successfully, some less so

A parent, A parent, PHYSICIANPHYSICIAN, or other , or other “provider” may assist an individual “provider” may assist an individual with his / her developmental tasks.with his / her developmental tasks.

Family Doctors’ Diagnostic Process Family Doctors’ Diagnostic Process ** (1) (1)

Influenced by awareness of what a Influenced by awareness of what a patient wants: patient wants:

To be: Seen To be: Seen Heard Heard UnderstoodUnderstood Diagnosed Diagnosed Given an explanationGiven an explanation Given a solutionGiven a solution

*optimal*optimal

Family Doctors’ Diagnostic Process Family Doctors’ Diagnostic Process ** (2) (2)

Depends on a professional relationship Depends on a professional relationship that:that:

Is carried out over time Is carried out over time Is influenced by cues gathered from a Is influenced by cues gathered from a

patient’s bio-psycho-social-ethical-patient’s bio-psycho-social-ethical-spiritual issuesspiritual issues

recognizes that the doctor has a recognizes that the doctor has a ““privileged privileged ” relationship that permits ” relationship that permits him / her to “him / her to “bear witnessbear witness” to changes ” to changes in the mind, body, and soul of ones in the mind, body, and soul of ones patients.patients.

*Optimal*Optimal

Family Doctors’ Diagnostic Process Family Doctors’ Diagnostic Process ** (3) (3) Involves direct contact with a patientInvolves direct contact with a patient

Influenced by doctors’ awareness of relevant Influenced by doctors’ awareness of relevant aspects of a patient’s life through the care for aspects of a patient’s life through the care for other “family” (significant others) membersother “family” (significant others) members

Realism: Realism: Can’t always care for family members– Can’t always care for family members–

depend on understanding generic life span depend on understanding generic life span issues , e.g. young adults are pre-occupied issues , e.g. young adults are pre-occupied with career advancementwith career advancement

*Optimal*Optimal

Terminology: Disease vs. Illness Terminology: Disease vs. Illness **

Disease: the pathophysiological Disease: the pathophysiological manifestation of disruption of manifestation of disruption of biological homeostasisbiological homeostasis

Illness: the impact that a disease Illness: the impact that a disease has on an individual ‘s ( family) has on an individual ‘s ( family) physical and /or psychological being physical and /or psychological being and , lifestyle, etcand , lifestyle, etc

*Kleinman *Kleinman et al et al

Illness ModelIllness Model**

Questions that could be asked directly or Questions that could be asked directly or indirectly:indirectly:

(1) What do you think caused your problem?(1) What do you think caused your problem?(2) Why do you think it started when it did?(2) Why do you think it started when it did?(3) What does the illness do to you?(3) What does the illness do to you?(4) How severe do you perceive it to be?(4) How severe do you perceive it to be?(5) What treatment do you expect for your (5) What treatment do you expect for your

problem?problem?(6) What results do you expect from the (6) What results do you expect from the

treatment?treatment?(7) What fear (if any) do you have of your illness?(7) What fear (if any) do you have of your illness?

* Kleinman et al* Kleinman et al

Impact of Illness (1)Impact of Illness (1)

Medication: cost, side-effectsMedication: cost, side-effects DisabilityDisability Psychological DistressPsychological Distress Impairment of Social FunctioningImpairment of Social Functioning Altered Relationship with Altered Relationship with

Family/FriendsFamily/Friends

Impact of Illness (2)Impact of Illness (2) PainPain Sleep DisturbanceSleep Disturbance Job, EarningsJob, Earnings Self-Perception : New diagnosis of Self-Perception : New diagnosis of

Hypertension assoc. with increased job Hypertension assoc. with increased job absenteeism (not caused by the absenteeism (not caused by the hypertension)hypertension)

Dynamic and Competing Pressures Dynamic and Competing Pressures and Interactionsand Interactions

ExpectationsExpectations

AttitudesAttitudes

MoralsMorals

PrioritiesPriorities

RulesRules

ValuesValues

StandardsStandards

Self

Family

Employer

An AnecdoteAn Anecdote

Thanks to a Thanks to a great great Professor!Professor!

Personal, Job, & Family StressorsPersonal, Job, & Family Stressors Strain of making decisions and judgement calls, Strain of making decisions and judgement calls,

particularly those done under pressureparticularly those done under pressure Maintaining knowledge, skills, and credibility in the Maintaining knowledge, skills, and credibility in the

field / discipline in which one worksfield / discipline in which one works Change imposed from “outside” or “above”Change imposed from “outside” or “above” Organizational audits of your performanceOrganizational audits of your performance Volumes of mailVolumes of mail With aging, multi-tasking is not as easyWith aging, multi-tasking is not as easy Finances (Moon-lighting on the side)Finances (Moon-lighting on the side) Children: Pregnancy, nurturing, attention, Children: Pregnancy, nurturing, attention,

consumerismconsumerism Spouses / intimate others: emotional, nurturance, Spouses / intimate others: emotional, nurturance,

sexual intimacy, career, lifestylesexual intimacy, career, lifestyle Aging parentsAging parents Community expectations ( ? more committees) Community expectations ( ? more committees)

Magical ThinkingMagical Thinking Managers are problem-solvers: “ I will Managers are problem-solvers: “ I will

handle this problem….I’ve always solved handle this problem….I’ve always solved things”….may lead to cumulative, things”….may lead to cumulative, sometimes unnoticed stress symptomssometimes unnoticed stress symptoms

Some managers may become accustomed to Some managers may become accustomed to solving the organization’s or others solving the organization’s or others problems, but ignore their own… problems, but ignore their own…

There may be a continuous organizational There may be a continuous organizational expectation of high performance……creating expectation of high performance……creating inappropriate sense of power inappropriate sense of power (…like some MDs) (…like some MDs) ….It can be intoxicating…..….It can be intoxicating…..

Example of Magical ThinkingExample of Magical Thinking

What do I hear from What do I hear from somesome McGill staff? McGill staff?

Are more people at risk for stress?Are more people at risk for stress?

Are we evolving a culture of Are we evolving a culture of managers?managers?

Increasing number of vice-principalsIncreasing number of vice-principals Addition of associate vice –principalsAddition of associate vice –principals Creation of provosts, vice-provostsCreation of provosts, vice-provosts More associate chairs and associate More associate chairs and associate

directors.directors.

Do inconsistent decision-making styles stress Do inconsistent decision-making styles stress employees and create health concerns?employees and create health concerns?

Motivation…..DemotivationMotivation…..Demotivation

Impact of StressorsImpact of Stressors

Not all people exposed to the same Not all people exposed to the same stressors develop symptoms or illnessstressors develop symptoms or illness

Intervening factors include physical Intervening factors include physical factors, emotional “make-up”, factors, emotional “make-up”, genetic endowment, previous life genetic endowment, previous life experience.experience.

Manifestations of stress may not Manifestations of stress may not appear as “job impairment”, but in appear as “job impairment”, but in fluctuating ability to do a jobfluctuating ability to do a job

Signs & Symptoms of StressSigns & Symptoms of Stress**(1)(1) Reluctance or dread in going to workReluctance or dread in going to work Chronic complaining to colleagues or Chronic complaining to colleagues or

superiorssuperiors Taking more time off to “re-charge”Taking more time off to “re-charge” Low patience with members of work Low patience with members of work

team or familyteam or family Increasing pre-occupation with Increasing pre-occupation with

income /financial securityincome /financial security Frequent turning to colleagues for Frequent turning to colleagues for

help with emotional needshelp with emotional needs

*M*Modified fromodified from physician impairment literaturephysician impairment literature

Signs & Symptoms of Stress(2)Signs & Symptoms of Stress(2) Fantasies about early retirement, Fantasies about early retirement,

time spent doing other things, time spent doing other things, change in jobchange in job

Inappropriate anger towards spouse, Inappropriate anger towards spouse, significant others, family, friends, significant others, family, friends, colleagues, superiorscolleagues, superiors

Deceased ability to focusDeceased ability to focus Difficulty in making decisions / wrong Difficulty in making decisions / wrong

decisions in professional /personal decisions in professional /personal lifelife

Decreased ability to hear the needs of Decreased ability to hear the needs of familyfamily

Clinical Anxiety or DepressionClinical Anxiety or Depression

Signs & Symptoms of Stress(3)Signs & Symptoms of Stress(3) Inability to physically relax : tense Inability to physically relax : tense

musclesmuscles Frequent degrading of peersFrequent degrading of peers Inappropriate use of alcohol, drugs, Inappropriate use of alcohol, drugs,

gamblinggambling Interrupted sleepInterrupted sleep Sense of meaninglessness, isolation, Sense of meaninglessness, isolation,

loss of confidenceloss of confidence Loss of ability to pace oneselfLoss of ability to pace oneself Loss of sense of humourLoss of sense of humour Libido change / sexual dysfunctionLibido change / sexual dysfunction Headache, backache, abdominal painHeadache, backache, abdominal pain

Life Stressors & Aging WellLife Stressors & Aging Well

What does “aging well” mean?What does “aging well” mean? What are the assumptions What are the assumptions

underlying aging underlying aging wellwell?? How do we prepare to age How do we prepare to age wellwell?? Is the term Is the term well-aging well-aging

judgemental?judgemental? Do you “fail” if you don’t age Do you “fail” if you don’t age

well?well?

AGE “WELL”AGE “WELL”

HealthilyHealthily In a good In a good wayway

AdmirablyAdmirably

PleasantlyPleasantly FavourablyFavourably ProperlyProperly

AcceptablyAcceptably CorrectlyCorrectly SuitablySuitably

AgreeablyAgreeably PerfectlyPerfectly SatisfactorilySatisfactorily

AGE “ WELL”AGE “ WELL”

Genetic PredispositionGenetic Predisposition Environmental Factors (good/bad)Environmental Factors (good/bad) Disease Course /Gradients/ ImpactsDisease Course /Gradients/ Impacts Coping Styles……AttitudesCoping Styles……Attitudes Support Systems Support Systems FinancesFinances Risk FactorsRisk Factors

Illness May be Normative, Illness May be Normative, (not isolated incidents).(not isolated incidents).

Living longer because of new technologies Living longer because of new technologies and medicationsand medications

Canada -Population: 31,752, 842Canada -Population: 31,752, 842

16,000, 000 live personally or through 16,000, 000 live personally or through family with chronic disease. family with chronic disease.

**Canadian Chronic Disease Prevention CentreCanadian Chronic Disease Prevention Centre

What is chronic disease?What is chronic disease?**

Usually:Usually: non-infectious originsnon-infectious origins uncertain causeuncertain cause multiple risk factors multiple risk factors slow to developslow to develop prolonged afflictionprolonged affliction impairment/functional impairment/functional

disability.disability.

*CCDPC*CCDPC

Chronic DiseaseChronic Disease

Some forms of heart diseaseSome forms of heart disease StrokeStroke Neurodegenerative disordersNeurodegenerative disorders Chronic respiratory diseaseChronic respiratory disease DiabetesDiabetes Some mental disordersSome mental disorders CancerCancer Degenerative musculoskeletal Degenerative musculoskeletal

disordersdisorders

Burden of Chronic DiseaseBurden of Chronic Disease By 2020 non-communicable By 2020 non-communicable

disease will globally account for disease will globally account for 73% of deaths and 60% of 73% of deaths and 60% of disease burdendisease burden

Some chronic diseases have Some chronic diseases have commonality in the impact they commonality in the impact they have on families: have on families:

Family CaregivingFamily Caregiving

Family Caregiving : Family Caregiving : A workforce stressorA workforce stressor

Not a new reality, but an Not a new reality, but an increasing occurrence for adults increasing occurrence for adults of all ages since , from newborns of all ages since , from newborns to elderly, people are living to elderly, people are living longer with more complex longer with more complex illnessesillnesses

Often reduces the physical and Often reduces the physical and emotional resources of those in emotional resources of those in the work force the work force

Family Caregiving TasksFamily Caregiving Tasks**

Assisting a dependent person with Assisting a dependent person with daily living: daily living:

Eating, meal preparation, Eating, meal preparation, shopping, banking, dressing, shopping, banking, dressing, bathing, toileting, transportationbathing, toileting, transportation

Giving medicationGiving medication Emotional supportEmotional support Help with decision-makingHelp with decision-making Attendance at doctors’ Attendance at doctors’

appointmentsappointments *partial list*partial list

Impact of Family Caregiving? (1)Impact of Family Caregiving? (1) PositivesPositives: often hard to see (increased contact, : often hard to see (increased contact,

gratification, giving back)gratification, giving back)

Negatives:Negatives: --Competing needs for ones time for:--Competing needs for ones time for: SelfSelf Spouse (intimate other)Spouse (intimate other) Children and other family membersChildren and other family members Recreation and fitnessRecreation and fitness Work (work day and take-home)Work (work day and take-home) --Increased expenses ( ?? unexpected)--Increased expenses ( ?? unexpected)

-- Emotional: Denial, Anger, Bargaining, -- Emotional: Denial, Anger, Bargaining, Guilt, Guilt, Depression, Anxiety, insomniaDepression, Anxiety, insomnia

Impact of Family Caregiving (2)Impact of Family Caregiving (2) Doctors commonly see symptoms & illness Doctors commonly see symptoms & illness

directly linked to CG burden .directly linked to CG burden .

CG die earlier than non-caregiversCG die earlier than non-caregivers

Daily preoccupation with CG likely lowers Daily preoccupation with CG likely lowers efficiency and creativity at work.efficiency and creativity at work.

CG is often an undeclared cause of job CG is often an undeclared cause of job absenteeism because stress is not a absenteeism because stress is not a recognized diagnosis for medical disability - recognized diagnosis for medical disability - doctors forced to be creative with medical doctors forced to be creative with medical form completion.form completion.

Impact of Family Caregiving (3)Impact of Family Caregiving (3) Some CGs are unhappy with absence of “fair” Some CGs are unhappy with absence of “fair”

treatment: If the “clock” and criteria for treatment: If the “clock” and criteria for promotion / advancement takes into account promotion / advancement takes into account pregnancy /maternity leaves, shouldn’t the “clock” pregnancy /maternity leaves, shouldn’t the “clock” reflect the social and normative reality of CG?reflect the social and normative reality of CG?

““my CG role exhausts me……it not severe enough for my CG role exhausts me……it not severe enough for my boss to recognize since my performance is my boss to recognize since my performance is passable”passable”

“ “ I can’t compete….I have no time for “out of hours” I can’t compete….I have no time for “out of hours” work.” work.”

““my CG financial obligations may force me to leave my CG financial obligations may force me to leave this job”this job”

Caregiver Literature: CGs are gradually forced to Caregiver Literature: CGs are gradually forced to decrease their career ambitions! decrease their career ambitions!

Impact of Family Caregiving (4)Impact of Family Caregiving (4)Financial:Financial:

When an employer adjusts salary on the basis of When an employer adjusts salary on the basis of comparative performance, there may be potential for CGs comparative performance, there may be potential for CGs to lose out to lose out

McGill: A larger fraction of academic annual salary McGill: A larger fraction of academic annual salary increment is via merit (3.23%) vs. across the board increment is via merit (3.23%) vs. across the board (1.25%)(1.25%)

Across the board is +/- COLA based on Montreal economic Across the board is +/- COLA based on Montreal economic indicators---yet inflation rates for health care (ie for CGs) indicators---yet inflation rates for health care (ie for CGs) far exceeds Bank of Canada annual inflation ratesfar exceeds Bank of Canada annual inflation rates

Non-public nursing home: $60,000/yrNon-public nursing home: $60,000/yr Supplementation of RNA care (10hrs/day): $80,000Supplementation of RNA care (10hrs/day): $80,000

For CGs decreased sense of financial control for self/family For CGs decreased sense of financial control for self/family produces less sense of ……“personal commitment to the produces less sense of ……“personal commitment to the university”university”

What can be done to help?What can be done to help?

Despite the fact that Prevention Despite the fact that Prevention against disease is strongly against disease is strongly advocated, North American advocated, North American health and social services tend health and social services tend to be more Curative (Reactive) to be more Curative (Reactive) than Preventativethan Preventative

Recognition of Family CaregivingRecognition of Family Caregiving Social reality that will only growSocial reality that will only grow

Israel: 30 doctor-certified paid days of leave /yr. Israel: 30 doctor-certified paid days of leave /yr. to assist with CG issues.to assist with CG issues.

Some North American companies are looking at Some North American companies are looking at CG leave / job sharing options.CG leave / job sharing options.

Some organizations are considering CGs be Some organizations are considering CGs be included in equity guidelines.included in equity guidelines.

Employees should consider the potential benefits Employees should consider the potential benefits of higher health premiums for better health care of higher health premiums for better health care coverage.coverage.

Should universities, promoters of knowledge Should universities, promoters of knowledge translation, explore further the needs of its translation, explore further the needs of its caregiver employees? caregiver employees?

What do patients want?What do patients want?

To be: (1) Seen To be: (1) Seen (2) Heard (2) Heard (3) Understood(3) Understood (4) Diagnosed (4) Diagnosed (5) Given an explanation(5) Given an explanation (6) Given a solution(6) Given a solution

What do PEOPLE wantWhat do PEOPLE want

7) Not to become patients7) Not to become patients

8) To have the means to avoid8) To have the means to avoid

preventable problemspreventable problems

9) To have perspective to deal9) To have perspective to deal

with situations over which onewith situations over which one

may not have controlmay not have control