1. Stress from Work, Personal and Family Life: Perspectives of a Family Physician Mark J. Yaffe, MDCM, MClSc, CCFP, FCFP Associate Professor of Family Medicine, McGill University and St. Mary’s Hospital Centre

2. Disclosure Someone in this room likely authorizes that part of my income that comes from McGill Someone in this room likely authorizes that part of my income that comes from McGill Longstanding clinical and research interests in today’s topic Longstanding clinical and research interests in today’s topic Some McGill employees in my practice Some McGill employees in my practice Up to ½ of my professional time has been spent as a manager for educational or health care delivery issues Up to ½ of my professional time has been spent as a manager for educational or health care delivery issues Many years of trying to juggle home life, professional life, & family caregiver responsibilities for 3 family members with serious chronic illness. Many years of trying to juggle home life, professional life, & family caregiver responsibilities for 3 family members with serious chronic illness.

3. Overview of Presentation (1) Why is a FP interested in this topic and from what perspective? (2) Look at examples of competing needs and some life stressors (3) Stressors I have heard from some McGill staff? (4) Discuss signs & symptoms of stress (5) What is “well aging”? (6) What is chronic disease, & the role it plays in our lives? (7) Family Caregiving as a major stressor (8) Opportunities for change

4. What is a Family Doctor ? * Generalist Generalist Cares for both sexes Cares for both sexes All ages All ages Holistic care Holistic care Aware of and responds to biological, psychological, social, ethical, & spiritual needs of patients Aware of and responds to biological, psychological, social, ethical, & spiritual needs of patients Has a specific diagnostic process Has a specific diagnostic process *optimal *optimal

5. Developmental Tasks Life span (life cycle) literature talks of predictable challenges in personal development, relationships, & jobs that each of us must face—some handled successfully, some less so Life span (life cycle) literature talks of predictable challenges in personal development, relationships, & jobs that each of us must face—some handled successfully, some less so A parent, PHYSICIAN, or other “provider” may assist an individual with his / her developmental tasks. A parent, PHYSICIAN, or other “provider” may assist an individual with his / her developmental tasks.

6. Family Doctors’ Diagnostic Process * (1) Influenced by awareness of what a patient wants: Influenced by awareness of what a patient wants: To be: Seen To be: Seen Heard Heard Understood Understood Diagnosed Diagnosed Given an explanation Given an explanation Given a solution Given a solution *optimal *optimal

7. Family Doctors’ Diagnostic Process * (2) Depends on a professional relationship that: Is carried out over time Is carried out over time Is influenced by cues gathered from a patient’s bio-psycho-social-ethical- spiritual issues Is influenced by cues gathered from a patient’s bio-psycho-social-ethical- spiritual issues recognizes that the doctor has a “privileged ” relationship that permits him / her to “bear witness” to changes in the mind, body, and soul of ones patients. recognizes that the doctor has a “privileged ” relationship that permits him / her to “bear witness” to changes in the mind, body, and soul of ones patients. *Optimal *Optimal

8. Family Doctors’ Diagnostic Process * (3) Involves direct contact with a patient Involves direct contact with a patient Influenced by doctors’ awareness of relevant aspects of a patient’s life through the care for other “family” (significant others) members Influenced by doctors’ awareness of relevant aspects of a patient’s life through the care for other “family” (significant others) members Realism: Realism: Can’t always care for family members– depend on understanding generic life span issues, e.g. young adults are pre-occupied with career advancement Can’t always care for family members– depend on understanding generic life span issues, e.g. young adults are pre-occupied with career advancement *Optimal *Optimal

9. Terminology: Disease vs. Illness * Disease: the pathophysiological manifestation of disruption of biological homeostasis Disease: the pathophysiological manifestation of disruption of biological homeostasis Illness: the impact that a disease has on an individual ‘s ( family) physical and /or psychological being and, lifestyle, etc Illness: the impact that a disease has on an individual ‘s ( family) physical and /or psychological being and, lifestyle, etc *Kleinman et al *Kleinman et al

10. Illness Model* Questions that could be asked directly or indirectly: (1) What do you think caused your problem? (2) Why do you think it started when it did? (3) What does the illness do to you? (4) How severe do you perceive it to be? (5) What treatment do you expect for your problem? (6) What results do you expect from the treatment? (7) What fear (if any) do you have of your illness? * Kleinman et al

11. Impact of Illness (1) Medication: cost, side-effects Medication: cost, side-effects Disability Disability Psychological Distress Psychological Distress Impairment of Social Functioning Impairment of Social Functioning Altered Relationship with Family/Friends Altered Relationship with Family/Friends

12. Impact of Illness (2) Pain Pain Sleep Disturbance Sleep Disturbance Job, Earnings Job, Earnings Self-Perception : New diagnosis of Hypertension assoc. with increased job absenteeism (not caused by the hypertension) Self-Perception : New diagnosis of Hypertension assoc. with increased job absenteeism (not caused by the hypertension)

13. Dynamic and Competing Pressures and Interactions Expectations Expectations Attitudes Attitudes Morals Morals Priorities Priorities Rules Rules Values Values Standards Standards Self Family Employer

14. An Anecdote Thanks to a great Professor!

15. Personal, Job, & Family Stressors Strain of making decisions and judgement calls, particularly those done under pressure Strain of making decisions and judgement calls, particularly those done under pressure Maintaining knowledge, skills, and credibility in the field / discipline in which one works Maintaining knowledge, skills, and credibility in the field / discipline in which one works Change imposed from “outside” or “above” Change imposed from “outside” or “above” Organizational audits of your performance Organizational audits of your performance Volumes of mail Volumes of mail With aging, multi-tasking is not as easy With aging, multi-tasking is not as easy Finances (Moon-lighting on the side) Finances (Moon-lighting on the side) Children: Pregnancy, nurturing, attention, consumerism Children: Pregnancy, nurturing, attention, consumerism Spouses / intimate others: emotional, nurturance, sexual intimacy, career, lifestyle Spouses / intimate others: emotional, nurturance, sexual intimacy, career, lifestyle Aging parents Aging parents Community expectations ( ? more committees) Community expectations ( ? more committees)

16. Magical Thinking Managers are problem-solvers: “ I will handle this problem….I’ve always solved things”….may lead to cumulative, sometimes unnoticed stress symptoms Managers are problem-solvers: “ I will handle this problem….I’ve always solved things”….may lead to cumulative, sometimes unnoticed stress symptoms Some managers may become accustomed to solving the organization’s or others problems, but ignore their own… Some managers may become accustomed to solving the organization’s or others problems, but ignore their own… There may be a continuous organizational expectation of high performance……creating inappropriate sense of power (…like some MDs) ….It can be intoxicating….. There may be a continuous organizational expectation of high performance……creating inappropriate sense of power (…like some MDs) ….It can be intoxicating…..

17. Example of Magical Thinking

18. What do I hear from some McGill staff? Are more people at risk for stress? Are we evolving a culture of managers? Increasing number of vice-principals Increasing number of vice-principals Addition of associate vice –principals Addition of associate vice –principals Creation of provosts, vice-provosts Creation of provosts, vice-provosts More associate chairs and associate directors. More associate chairs and associate directors.

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

21. Motivation…..Demotivation

22. Impact of Stressors Not all people exposed to the same stressors develop symptoms or illness Not all people exposed to the same stressors develop symptoms or illness Intervening factors include physical factors, emotional “make-up”, genetic endowment, previous life experience. Intervening factors include physical factors, emotional “make-up”, genetic endowment, previous life experience. Manifestations of stress may not appear as “job impairment”, but in fluctuating ability to do a job Manifestations of stress may not appear as “job impairment”, but in fluctuating ability to do a job

23. Signs & Symptoms of Stress*(1) Reluctance or dread in going to work Reluctance or dread in going to work Chronic complaining to colleagues or superiors Chronic complaining to colleagues or superiors Taking more time off to “re-charge” Taking more time off to “re-charge” Low patience with members of work team or family Low patience with members of work team or family Increasing pre-occupation with income /financial security Increasing pre-occupation with income /financial security Frequent turning to colleagues for help with emotional needs Frequent turning to colleagues for help with emotional needs *M odified from physician impairment literature

24. Signs & Symptoms of Stress(2) Fantasies about early retirement, time spent doing other things, change in job Fantasies about early retirement, time spent doing other things, change in job Inappropriate anger towards spouse, significant others, family, friends, colleagues, superiors Inappropriate anger towards spouse, significant others, family, friends, colleagues, superiors Deceased ability to focus Deceased ability to focus Difficulty in making decisions / wrong decisions in professional /personal life Difficulty in making decisions / wrong decisions in professional /personal life Decreased ability to hear the needs of family Decreased ability to hear the needs of family Clinical Anxiety or Depression Clinical Anxiety or Depression

25. Signs & Symptoms of Stress(3) Inability to physically relax : tense muscles Inability to physically relax : tense muscles Frequent degrading of peers Frequent degrading of peers Inappropriate use of alcohol, drugs, gambling Inappropriate use of alcohol, drugs, gambling Interrupted sleep Interrupted sleep Sense of meaninglessness, isolation, loss of confidence Sense of meaninglessness, isolation, loss of confidence Loss of ability to pace oneself Loss of ability to pace oneself Loss of sense of humour Loss of sense of humour Libido change / sexual dysfunction Libido change / sexual dysfunction Headache, backache, abdominal pain Headache, backache, abdominal pain

29. Life Stressors & Aging Well What does “aging well” mean? What does “aging well” mean? What are the assumptions underlying aging well? What are the assumptions underlying aging well? How do we prepare to age well? How do we prepare to age well? Is the term well-aging judgemental? Is the term well-aging judgemental? Do you “fail” if you don’t age well? Do you “fail” if you don’t age well?

30. AGE “WELL” Healthily In a good way Admirably PleasantlyFavourablyProperly AcceptablyCorrectlySuitably AgreeablyPerfectlySatisfactorily

31. AGE “ WELL” Genetic Predisposition Genetic Predisposition Environmental Factors (good/bad) Environmental Factors (good/bad) Disease Course /Gradients/ Impacts Disease Course /Gradients/ Impacts Coping Styles……Attitudes Coping Styles……Attitudes Support Systems Support Systems Finances Finances Risk Factors Risk Factors

32. Illness May be Normative, (not isolated incidents). Living longer because of new technologies and medications Living longer because of new technologies and medications Canada -Population: 31,752, 842 Canada -Population: 31,752, 842 16,000, 000 live personally or through family with chronic disease. 16,000, 000 live personally or through family with chronic disease. * Canadian Chronic Disease Prevention Centre

33. What is chronic disease?* Usually: non-infectious origins non-infectious origins uncertain cause uncertain cause multiple risk factors multiple risk factors slow to develop slow to develop prolonged affliction prolonged affliction impairment/functional disability. impairment/functional disability. *CCDPC *CCDPC

34. Chronic Disease Some forms of heart disease Some forms of heart disease Stroke Stroke Neurodegenerative disorders Neurodegenerative disorders Chronic respiratory disease Chronic respiratory disease Diabetes Diabetes Some mental disorders Some mental disorders Cancer Cancer Degenerative musculoskeletal disorders Degenerative musculoskeletal disorders

35. Burden of Chronic Disease By 2020 non-communicable disease will globally account for 73% of deaths and 60% of disease burden By 2020 non-communicable disease will globally account for 73% of deaths and 60% of disease burden Some chronic diseases have commonality in the impact they have on families: Some chronic diseases have commonality in the impact they have on families: Family Caregiving Family Caregiving

36. Family Caregiving : A workforce stressor Not a new reality, but an increasing occurrence for adults of all ages since, from newborns to elderly, people are living longer with more complex illnesses Not a new reality, but an increasing occurrence for adults of all ages since, from newborns to elderly, people are living longer with more complex illnesses Often reduces the physical and emotional resources of those in the work force Often reduces the physical and emotional resources of those in the work force

37. Family Caregiving Tasks* Assisting a dependent person with daily living: Eating, meal preparation, shopping, banking, dressing, bathing, toileting, transportation Eating, meal preparation, shopping, banking, dressing, bathing, toileting, transportation Giving medication Giving medication Emotional support Emotional support Help with decision-making Help with decision-making Attendance at doctors’ appointments Attendance at doctors’ appointments *partial list *partial list

38. Impact of Family Caregiving? (1) Positives: often hard to see (increased contact, gratification, giving back) Positives: often hard to see (increased contact, gratification, giving back) Negatives: Negatives: --Competing needs for ones time for: --Competing needs for ones time for: Self Self Spouse (intimate other) Spouse (intimate other) Children and other family members Children and other family members Recreation and fitness Recreation and fitness Work (work day and take-home) Work (work day and take-home) --Increased expenses ( ?? unexpected) --Increased expenses ( ?? unexpected) -- Emotional: Denial, Anger, Bargaining, Guilt, Depression, Anxiety, insomnia -- Emotional: Denial, Anger, Bargaining, Guilt, Depression, Anxiety, insomnia

39. Impact of Family Caregiving (2) Doctors commonly see symptoms & illness directly linked to CG burden. Doctors commonly see symptoms & illness directly linked to CG burden. CG die earlier than non-caregivers CG die earlier than non-caregivers Daily preoccupation with CG likely lowers efficiency and creativity at work. Daily preoccupation with CG likely lowers efficiency and creativity at work. CG is often an undeclared cause of job absenteeism because stress is not a recognized diagnosis for medical disability - doctors forced to be creative with medical form completion. CG is often an undeclared cause of job absenteeism because stress is not a recognized diagnosis for medical disability - doctors forced to be creative with medical form completion.

40. Impact of Family Caregiving (3) Some CGs are unhappy with absence of “fair” treatment: If the “clock” and criteria for promotion / advancement takes into account pregnancy /maternity leaves, shouldn’t the “clock” reflect the social and normative reality of CG? Some CGs are unhappy with absence of “fair” treatment: If the “clock” and criteria for promotion / advancement takes into account pregnancy /maternity leaves, shouldn’t the “clock” reflect the social and normative reality of CG? “my CG role exhausts me……it not severe enough for my boss to recognize since my performance is passable” “my CG role exhausts me……it not severe enough for my boss to recognize since my performance is passable” “ I can’t compete….I have no time for “out of hours” work.” “ I can’t compete….I have no time for “out of hours” work.” “my CG financial obligations may force me to leave this job” “my CG financial obligations may force me to leave this job” Caregiver Literature: CGs are gradually forced to decrease their career ambitions! Caregiver Literature: CGs are gradually forced to decrease their career ambitions!

41. Impact of Family Caregiving (4) Financial: When an employer adjusts salary on the basis of comparative performance, there may be potential for CGs to lose out When an employer adjusts salary on the basis of comparative performance, there may be potential for CGs to lose out McGill: A larger fraction of academic annual salary increment is via merit (3.23%) vs. across the board (1.25%) McGill: A larger fraction of academic annual salary increment is via merit (3.23%) vs. across the board (1.25%) Across the board is +/- COLA based on Montreal economic indicators---yet inflation rates for health care (ie for CGs) far exceeds Bank of Canada annual inflation rates Across the board is +/- COLA based on Montreal economic indicators---yet inflation rates for health care (ie for CGs) far exceeds Bank of Canada annual inflation rates Non-public nursing home: $60,000/yr Non-public nursing home: $60,000/yr Supplementation of RNA care (10hrs/day): $80,000 Supplementation of RNA care (10hrs/day): $80,000 For CGs decreased sense of financial control for self/family produces less sense of ……“personal commitment to the university” For CGs decreased sense of financial control for self/family produces less sense of ……“personal commitment to the university”

43. What can be done to help? Despite the fact that Prevention against disease is strongly advocated, North American health and social services tend to be more Curative (Reactive) than Preventative Despite the fact that Prevention against disease is strongly advocated, North American health and social services tend to be more Curative (Reactive) than Preventative

44. Recognition of Family Caregiving Social reality that will only grow Social reality that will only grow Israel: 30 doctor-certified paid days of leave /yr. to assist with CG issues. Israel: 30 doctor-certified paid days of leave /yr. to assist with CG issues. Some North American companies are looking at CG leave / job sharing options. Some North American companies are looking at CG leave / job sharing options. Some organizations are considering CGs be included in equity guidelines. Some organizations are considering CGs be included in equity guidelines. Employees should consider the potential benefits of higher health premiums for better health care coverage. Employees should consider the potential benefits of higher health premiums for better health care coverage. Should universities, promoters of knowledge translation, explore further the needs of its caregiver employees? Should universities, promoters of knowledge translation, explore further the needs of its caregiver employees?

45. 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

46. What do PEOPLE want 7) Not to become patients 8) To have the means to avoid preventable problems preventable problems 9) To have perspective to deal with situations over which one with situations over which one may not have control may not have control