Understanding physician stress (Part Two)

In the first article on physician stress (Pharmaceutical Representative, Jan. 2001), we reviewed behavior of practicing physicians that might interfere with successful interaction with pharmaceutical representatives.

The thesis we presented was that understanding physician stressors and the behavior that follows was one key to enhancing relationships.

In addition, the demeaning behavior experienced by sales representatives is not to be taken personally, as it is often the result of other factors of which the physician is unaware. In the final segment of our article on physician stress, we present additional material to assist reps' understanding of physicians. Our goal is to provide insight that will lead to improvement in the quality of interaction between pharmaceutical representatives and physicians.

Loss of autonomy

The perceived loss of professional autonomy is a major factor that influences physician thinking and behavior today, and several social and economic forces have eroded that autonomy.

Physician work has traditionally been reviewed and judged only by physicians. Today, nonphysicians review physician work at many levels. This occurs with regularity in reviews by insurance companies and at the governmental level. Additionally, physicians' autonomy in the choice of pharmaceutical agents has been eroded as pharmacy and therapeutics committees choose which drugs to list in hospital formularies. Patients also come to the physician armed with information they have obtained from the Internet. Many times, the detail they bring is not only more than the physician might have, but is also presented in a way that again challenges physician autonomy. Television advertising creates increased demand for patients to request certain drug therapies that are presented with implied promises of a better and richer life if the drug is used. Pharmaceutical representatives often find themselves directly in the firing line of frustrations fueled by the issues mentioned above.

Some behaviors seen in the physician may be manifested as a result of this perceived loss of autonomy and may be extremely fear-driven. Fear-driven behavior can show up as anger, aloofness, sullenness and, ultimately, depression. For the pharmaceutical representative, angry behavior may commonly be seen, may be totally out of context and may arise from some comment that initially seemed rather innocuous. One way to deal with this anger is to approach it directly and ask the physician if an issue has arisen that the representative is unaware of. It is not appropriate to run from anger or an outburst. This only serves to widen the distance between the parties. Often a physician (or any individual) caught in this setting ultimately appreciates a direct approach to the problem. He or she may choose to speak about it, and an unexpected friendship may develop in this setting. Friendship and respect are worth more in a working relationship with the physician than any other commodity.

Interruptions in the schedule

Physician schedules are fuller and more complicated today than ever. The single office practice has given way to large groups practicing in multiple sites, often in multiple cities or adjacent towns. In many practices, the volume of patients scheduled would bend the capacity of any practitioner. Additional responsibilities facing the busy physician include some of the following: Patient care, where the patient is often more critically compromised, is rendered in hospitals, nursing homes and multiple practice sites. Hospital obligations, with increasing medical staff, rules and regulations, may include multiple meetings, creating medical records, medical staff committee assignments and participation, hospital politics, holding medical staff office, performing complex peer review, and consistent adherence to practice guidelines.

The current medico-legal aspects of practice exacerbate these obligations. Additional stress comes from having to attend to risk-reduction behaviors, and creating records that document care to avert or defend against professional misconduct allegations or legal action. Practice partners and group practice responsibilities include group governance, compensation, contracts, liability requirements, strategic planning, group board participation or officer obligations, and professional conduct rules. Additional responsibilities include changing reimbursement, capitation, absent owners, and changing relationships among specialists and generalists.

Physicians must meet payers' requirements for documentation and be aware of restrictions on referrals and other managed care rules, regulations and limitations on what can be done for patients. The government, corporate (as physicians become employees), managed care and supra-practice membership liabilities add regulations and responsibilities. The physician must meet complex and changing coding requirements with resultant sanctions for breaking rules. More physicians find it essential to engage in outside and health activist roles as a competitive or philosophical necessity. Continuing medical education is an added, mandated obligation that may seem to be an intrusive stress for physicians. Most of us participate in continuing medical education, as it is required for recertification in our specialties, hospital privileges, licensing (in some states), current competency and a "competitive advantage" in practice. Family issues round out the list, as values have changed for the modern physician. Spouses often are also professionals, and personal time is as important as professional obligations (unfortunately, personal time usually comes last of all, if it is even on the to-do list).

Physicians, like other professionals, juggle many roles in spite of finite hours in a week. An awareness of this partial list of obligations promotes both understanding and opportunities for empathy and assistance. Society and the medical profession have established unrealistic expectations. As physicians feel these clashes, frustration and emotional fatigue arise. Many physicians have trouble setting effective boundaries for themselves and become overloaded with their professional responsibilities. When an interaction with a pharmaceutical representative goes awry, some of the above dynamics may be in play.

Understanding these combined stressors allows representatives to empathize and relate to physicians' needs for understanding and help. For example, you may wish to define exactly how much time you need to educate them on your medicines, but also add some hints on time management (or a resource). Simply sharing any technique you have used to be more efficient will help. However, do not share these in a patronizing way, including phrases like "you should know," or "as you know from current literature." A positive strategy would be to encourage the physician with phrases such as "As choices are made, consider [blank]" or "If you would like cost-benefit data, I can share some." Information on subjects such as the usefulness of medical scribes can be shared from one busy person to another.

Attempting to "perfectly" balance all of his or her responsibilities predisposes the physician to be unable to deal with one more interruption. In this situation, you might find it better to set up an appointment. Perhaps the office in which the physician practices could set aside some regular time to see professional pharmaceutical representatives. Your participation with the office manager or physician agent in this activity might prove very successful and could pave the way for mutual listening and a regular audience with physicians. You must be willing to be flexible and offer solutions as a means of being more effective. This promotes communication and reduces frustration for all involved.

Win-win

Changes in patient care (especially the business of medicine) are evident in every facet of a physician's day. Embracing these changes without over-stressing is necessary for healthcare professionals and all other members of the healthcare community.

Physicians are besieged by unrealistic expectations and minimal understanding of their changing roles in the new environment. Understanding some components of physician distress, feelings of entitlement and the burden of unrealistic expectations will bring pharmaceutical representatives closer to their clients.

Practicing honest and direct communication is essential to good relations with physicians. The result can be a win-win scenario for both groups. PR