Dr. Steve Jackson, former President of the California Society of Anesthesiologists, has written a timely review that should be required reading for all clinicians and their families and close friends. It is insightful, witty and from the heart. I recognize the "iron in [his] words" and am trying to incorporate some of his multiple insights into my life. For instance, at least someone else is driving while I am dictating this summary. Now if I could sleep and exercise enough, spend more time with my loved ones, sweat the bullshit less, and feel good about such accomplishments, I will be set.

Simply put, Webster defines stress as "any mental or physical tension or strain." Dr. Jackson more broadly defines it as "a nonspecific adaptive response of the body to any change, demand, pressure, challenge, threat or trauma." He states that we use the stress response in an attempt to maintain our equilibrium, to survive in an increasingly hostile environment and to deal with the unpredictable, insensitive and, at times, unfair aspects of life. Stresses can be divided into extrinsic factors and intrinsic pressures that one initiates consciously or subconsciously. By definition, when one feels unable to cope with the demands to which he or she feels compelled to respond, that is stress. Both Dr. Jackson's timely review and a commentary by Dr. Jessie Leak in the August issue of the ASA Newsletter outline the importance of recognizing, acknowledging and learning to manage stress in a healthy fashion to avoid its potentially devastating consequences.

When compared to the general population, physicians suffer a significantly greater incidence of alcohol and drug abuse, depression, suicide, and psychiatric hospitalizations. Anesthesiologists have an even higher suicide rate and chemical dependence rate than the general physician population. However, little of this is talked about within our specialty and there is a paucity of medical education and training in stress management. Dr. Jackson reminds us of the need to identify stress and develop effective and healthy means to dissipate its effects.

Despite the huge advances in the practice of anesthesiology and improvement in patient safety during the past 25 to 30 years, Dr. Jackson feels anesthesiology is an increasingly dangerous specialty for its practitioners. As we "push the envelope" of patient care, anesthetizing sicker and more complex patients, we place increasing demands on our own performance. This is further compounded by the changes in the overall face of modern medical care including production pressures, cost issues, accountability and the ever-looming threats from a litigious society. Lurking in the background of these variables is the inevitable reality of aging and fatigue. In my current clinical practice as an anesthesiologist and intensivist, I find sleep deprivation the most sapping of features and it certainly hasn't slowed my aging. Fatigue and aging with their (additive or synergistic) effects on physical, intellectual and emotional health makes one realize why anesthesiology and intensive care are frequently referred to as fields for the young. Our field is not only challenging but a tough one in which to mature and age gracefully.

Dr. Jackson addresses additional issues such as self-worth, mid-life crises, and some of the gender-specific stresses that practitioners encounter. He discusses the unique pressures associated with private, academic and subspecialty practices, and reminds us of the physical demands of the anesthesia work environment including noise pollution, radiation, drug, infectious disease, and toxin exposure, environmental stresses of temperature and humidity, and our ergonometrically challenged work spaces.

It is no surprise after reading through this article that chemical dependence is a major risk factor for clinicians and that burnout has become increasingly commonplace. The syndrome of burnout is increased by the overall feelings of loss of professional autonomy, interference with patient-doctor relationship, limitations in patient advocacy, and the feeling of misappropriation of one's skills. Recent data on physician dissatisfaction is sobering. If they had to do it all over again, over a third of physicians would choose another career!

So, how do we quantify and control stress? Dr. Jackson supplies two exercises in the addendum of the article that allow us to get an estimate on how stressful our lives are. He outlines the consequences of prolonged, excessive, uncontrolled stress resulting in physical illness, emotional deterioration, behavioral abnormalities, and intellectual dysfunction. On a brighter note, he emphasizes that there are benefits from certain stresses and from evaluating how successful people deal with stress while applying those techniques to ourselves.

The second half of his commentary deals with aspects of successful stress management. He starts with emphasis on an approach to what he terms role-irrelevant stresses, including sleep deprivation, fatigue and status deprivation. He emphasizes that our "physician culture" belittles and overtly ignores the adverse consequences of sleep deprivation and fatigue. Jackson also points out something that we probably all learned in kindergarten: that a brief nap (for less than 30-45 minutes) can be a particularly effective means of dealing with fatigue.

Dr. Jackson beckons us to learn to disengage from the professional ego's need to feel indispensable and to not overlook our personal lives and human needs. He advises balance and satisfactory interpretation of one's performance as well as preventive maintenance and care including nutritional support, physical and emotional support, and establishment of external support networks.

In summary, call the library or your on-line service and get a hard copy of this fine article. Dr. Jackson has done the specialty a great service by reminding us that doctoring in and of itself is stressful and that there are new and evolving stressors. Fortunately, he presents methods to identify and limit stress in our practices and lives, and indirectly restates two truths: "The grave yards of the world are filled with essential men and women" (don't join them prematurely) and "He who laughs, lasts."