Understanding physician stress (Part One)

No current educational curriculum prepares pharmaceutical salespeople for their role in dealing with anguished and stressed-out clients. The emotional practice of medicine is unhealthy and rapidly deteriorating. It is therefore prudent to be better prepared for dysfunctional communication, should it arise.

Understanding the stress of physicians and other health professionals such as pharmacists allows representatives to enhance their rapport and relationships with these clients. Sales representatives can more quickly relate to clients if they understand the forces that promote stress and burnout. When physicians take out their frustrations during a detailing session, representatives may feel as though it is a personal attack on them. However, an astute representative - who knows how to recognize and deal with such situations - may try to avoid confrontations by calling in advance of the visit to request questions the physician would like answered, thereby controlling the direction of the conversation during the actual call.

Pharmaceutical sales representatives who understand how physicians develop a professional identity can prepare more realistically for working with physicians. An awareness of the maladaptive influences in physician socialization that lead to an inability to collaborate, receive constructive or negative feedback, or dispense positive feedback, broadens the communication ability of anyone in the role of physician educator.

A well-trained representative will not take the absence of positive feedback as a personal insult. For example, if physicians complain of the involvement of too many people in clinical decision-making (for example, pharmacists, nurse practitioners, managed care agents), sales representatives can use this opportunity to point out that these pressures could be improved through better collaboration. They may even offer tools to help the physician practice more effectively by sharing collaborative relationship-building tools. For example, they might demonstrate better listening skills and facilitate brainstorming sessions so that each person owns responsibility for the outcomes.

Physician socialization

During their training, physicians are taught to develop a role that is pleasing to their faculty, their peers and their potential patients. They are taught not to confront peers or colleagues, because to do so would appear to show a lack of control. Furthermore, any confrontation is perceived to be met by later retribution.

Physicians also are taught that they hold "final responsibility" for all matters affecting their patients, and that they will be held accountable if harm occurs. They are taught not to value partnering; rather, they are indoctrinated to act independently in decision-making. Thus, sharing risk with staff, the system, or even technological or pharmacological partners is at the very least uncomfortable and often inconceivable. They feel that the therapeutic bottom line is their personal responsibility. This is the essence of the physician's deep attachment to professional autonomy. Reporting possible errors is directly discouraged, and predictable risks are not addressed. The threat or occurrence of litigation greatly reinforces this aversion to admission of possible errors.

During training, physicians experience a great deal of disrespect from faculty, senior peers and even the nursing staff. This disrespect takes the form of sarcasm, cynicism and shame-based comments that help create an environment in which mistrust and defensive isolation grow. As the new physicians begin practice, the ultimate result of this exposure precludes amiable relationships with most of the salespeople who will call on them.

As a result, some physicians may even demand a disproportionate measure of respect. Demands for respect usually come from individuals with a reduced sense of self-esteem and a strong need to find respect from external sources. In medicine, such demands are often derived from the belief that respect has been earned from achievement and from compliments given by peers or faculty. However, the public and other members of the healthcare domain are not necessarily willing to give physicians that respect automatically.

When the unspoken demand for respect is unmet, the physician's response may be a childish one. For example, the lack of respect may increase not only the difficulty the physician may have in relating positively to a subordinate, but also the difficulty a physician may have in learning from anyone who is perceived to be a subordinate.

Physicians in training are shamed by their faculty, mentors and peers if they admit to a lack of knowledge. Unfortunately, this shame-based educational model carries over from training into practice. Thus, if the sales representative's educational efforts replay the trauma the physician remembers from training, the representative may be seen as an adversary rather than an advocate.

Finally, the reasons physicians frequently become difficult clients stem from their faculties' derision of business as pollution in comparison with the nobility of their calling as healers. Sales representatives and the pharmaceutical industry are portrayed as part of corporate America - greedy businesses using illness as a domain to ply a trade.

Physicians are aware that they are often poor negotiators and have limited business skills or experience. Therefore, interaction with sales representatives puts them in a vulnerable position. This is easier to avoid than to confront. Thus, relationships are difficult for both the representative, who may be shunned, and the physician, who may pay only cursory attention to the relationship. Shunning is not personal. It is derived from modeling and a fear of extroverted salespeople.

Physicians are taught to make decisions about clinical choices based upon academic and clinical protocols. Advice from clinical mentors (attendings) is taken as gospel, and physicians are taught to make independent clinical choices. Recommendations obviously based on a marketing scheme are viewed with suspicion, as are consumer ads touting prescription medications. Distrust of anyone marketing treatment choices is supported strongly in physician training. When patients appear with requests from alternative practitioners, TV or other media sources, physicians tend to feel upstaged, shamed and, therefore, inadequate.

Resistance to marketing techniques is engraved deeply into the evolving identity of young physicians. Therefore, it is important in this changing time that the presentation of clinical information be formatted to allow maximum autonomy for the provider. Likewise, understanding the many unpublicized components of physician socialization will improve communication and the relationships between physicians and sales representatives.

Pressures producing physician distress

Each specialty, age group, gender, tradition, and even geographic location of medical school or residency program has its own specific set of forces that contribute to physician distress. Additional considerations are derived from the organizational type of the physician's practice.

However, some common themes are associated with physicians' distress. In general, these have to do with outside forces dictating physician hours, number of patients seen and loss of control over clinical decisions, among others. Awareness of these forces can greatly enhance understanding, empathy and communication methods designed to align the goals of physicians with those of sales representatives. (See the sidebar for a general list of these forces.)

Insights for the sales representative

The sales representative needs to be aware of these pressures in order to blend more comfortably into the role of an acceptable healthcare educator. These insights are essential for the representative, and offerings in these areas serve as value-added programming for physicians. Such programming includes not only information on physician stress and socialization, but also skill training in mentoring, constructive feedback, litigation stress or other topics of this nature.

Under managed care, physicians feel an incessant pressure to produce, which goes against their guiding covenant to primarily respect the needs of their patients. So a key consideration is whether the information and products being presented can increase efficiency and efficacy or improve both patient care and provider satisfaction.

Physicians also unhappily perceive that patient care has become a numbers game. Therefore, any message associated with a representative's company, materials or presentations that conveys that doctors themselves are numbers will predictably alienate the physician.

Physicians bemoan the lack of acknowledgment for their own needs: personal, family, community, self-care and leisure. Therefore, any presentation that emphasizes helping physicians restore a sense of control will be well-received. Any skills or services representatives can provide to help doctors deal with personal tragedy, energy drain, balance or creativity will help reduce physician stress. As physicians become less distressed, they become more capable of focusing on educational offerings that help them practice quality care. Sales representatives should understand and develop ways to reduce physician stress associated with each of the items listed in the sidebar. The more representatives understand, the more effectively they will communicate with their physicians.

Those who successfully interact with physicians tailor their contacts so as to recognize and acknowledge the primacy of patient's needs, trust, physician well-being and integrity. Thus, they promote sustenance for a lifetime of practice. The results will be enhanced relationships, better communication and ultimately, the opportunity to improve patient care and continued success of pharmaceutical and medical practice. PR