REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiology www.sba.com.brREVIEW
ARTICLE
Work-related
mental
and
behaviour
disorders
in
anesthesiologists
Gabriela
Oliveira
Andrade
a,∗,
Rosa
Amélia
Andrade
Dantas
b,caDepartamentodeMedicinaPreventivaeSocialdaUniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil bUniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil
cUniversidadeFederaldeSergipe(UFS),SãoCristóvão,Sergipe,Brazil
Received14November2012;accepted20March2013 Availableonline28September2015
KEYWORDS
Anaesthesiology; Financingorganized; Psychologicalstress; Occupationaldiseases
Abstract
Background: Anaesthesiologyisaspecialtywhosespecificityoftheworkingprocessresultsin highlevelsofstressasaninevitablecondition---aparticularlyworryingsituationinthedaily lifeoftheseprofessionals.
Objectives:Thisstudy,basedondatafromnationalandinternationalliterature,aimstodiscuss thebasisoftheoccurrenceofmentalandbehaviouraldisordersorofpsychopathologicalinjuries (psychologicaldistress)relatedtoworkingactivityinanesthesiologists.
Method: A literature review was conducted, with papers selected fromMedline andLilacs databases,publishedbetween2000and2012inPortuguese,EnglishandSpanish,andaddressing thepossibleassociationbetweenoccupationalhazardsoftheanaesthesiologistprofessionand mentalhealthproblemsandpsychicdistress.Twenty-sixpublicationswerelisted.
Results:Severalaspectsoftheanesthesiologist’sworkareimportantpointstobetter under-standtherelationshipbetweenmentalhealthatworkandworkingorganization.Poortemporal structuringofwork,conflictuousinterpersonalrelationshipsandpoorcontrolovertheactivity itselfmaybementionedasillnessenhancers.
Conclusion:Theworkingorganization,whennotappropriate,isanimportantoccupationalrisk factorforthelifeandmentalhealthofworkers,mainlyofprofessionalsfocusedonthecare ofpeople.Thispaperfocusesonanesthesiologists,whoareconstantlyexposedtostressfuland anxiogenicfactors.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.
∗Correspondingauthor.
E-mail:euoandrade@yahoo.com.br(G.O.Andrade).
0104-0014/$–seefrontmatter©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE
Anestesiologia; Organizac¸ão; Estressepsicológico; Doenc¸asprofissionais
Transtornosmentaisedocomportamentorelacionadosaotrabalhoemmédicos anestesiologistas
Resumo
Justificativa: Aanestesiologiaéumaespecialidadecujaespecificidadedoprocessodetrabalho tornaelevadosníveisdeestresseumacondic¸ãoinevitável,situac¸ãopreocupantenocotidiano dessesprofissionais.
Objetivos: Opresenteestudo,fundamentadoemdadosdaliteraturanacionaleinternacional, temopropósitodediscutirasbasesdaocorrênciadetranstornosmentaisedecomportamento ouagravospsicopatológicos(sofrimentopsíquico)relacionadosàatividadelaboralemmédicos anestesiologistas.
Método: Fez-seuma revisãodeliteraturaem queforamselecionados artigoscientíficos nas basesdedadosMedlineeLilacs,publicadosentre2000e2012,emportuguês,inglêseespanhol, queabordamapossívelassociac¸ãoentreriscosocupacionaisdaprofissãodemédico anestesiol-ogistaeproblemasdesaúdementalesofrimentopsíquico.Foramenumeradas26publicac¸ões.
Resultados: Váriosaspectosdotrabalhodomédicoanestesiologistaapresentam-secomopontos importantesparaacompreensãodasrelac¸õesentresaúdementalnotrabalhoeorganizac¸ãodo trabalho.Podemserdestacadoscomoadoecedoresamáestruturac¸ãotemporaldotrabalho,as relac¸õesinterpessoaisconflituosaseomaucontrolesobreaprópriaatividade.
Conclusão:Aorganizac¸ãodotrabalho,quandonãoadequada,éumimportantefatorderisco ocupacionalparaavidaeasaúdementaldostrabalhadores,principalmente,dos profission-ais voltadospara o cuidado de pessoas. Ofoco presentesão os médicos anestesiologistas, constantementeexpostosafatoresestressanteseansiogênicos.
©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
InthisseconddecadeoftheXXIcentury,theoccurrenceof mentalandbehaviouraldisordersisincreasing.Among the variouscausalfactors,workingactivityappears toplayan importantroleinthedevelopmentandevolutionofpsychic disorders.1
Studiesonpsychologicalmorbidityinhealthworkers indi-cate thatamongthehigherlevelprofessionals, physicians arethosewhoexhibithighrates ofalcoholism,stress and depression,andalarge numberoftheseprofessionalsuse psychotropicor other drugs.In thiscontext,their workis seen as an important cause for such a situation.2 Sleep
disturbances,working permitsandabsenteeism causedby psychopathologicalproblems,depressiveandanxiety disor-dersandevensuicidalideationarealsorelated.3
Therefore,itisappropriateanattempttounderstandthe possibilityofassociationofmentalandbehaviouraldisorders relatedtophysicians’work,particularlyanesthesiologists’, sinceinevitablythisisaspecialtyinwhichthespecificityof theworkgenerateshighlevelsofstress,4,5mayberesulting
inimportantpsychicdistress,workdissatisfactionandeven aburnoutsyndrome.6,7Possiblyalltheseaspectsmakeeven
moreseriousthesituationoftheseprofessionals.
It is within this context that the present study aims todiscuss,based ondata fromnational andinternational literature, the foundations of the occurrence of mental and behavioural disorders or psychopathological diseases (psychicdistress) relatedtoworking activity in anesthesi-ologists.
Method
Aliteraturereviewofpublishedarticlesaboutmentaland behaviouraldisorders or psychopathologicaldiseases (psy-chicdistress) relatedtotheworkof anesthesiologistswas conducted.Toobtainthetheoreticalframework,only scien-tificarticleswereselectedfromtheVirtualHealthLibrary (VHL)withsearchofLilacs(LatinAmericanandCaribbean LiteratureonHealthSciences)andMedline(OnlineSystem searchand Analysisof MedicalLiterature)databases. The following keywords and their possible combinations by descriptors were used: sofrimento psíquico/psychological stress/estresse psicológico/estresse; saúde mental/
mental health/salud mental; trabalho/work/trabajo; médico/physician; anestesia/anesthesia/anaesthesia; anestesiologia/anesthesiology;anestesiologista/ anaesthes-iologist/anaesthetist/anestesiólogo/anestesista.
Theinclusioncriteriawere:articlespublishedinEnglish, PortugueseandSpanishfromJanuary2000toMay2012and thataddressedthepossibleassociationbetweenthetheme ‘‘anaesthesiologists’work’’andaspectsrelatedtomental healthproblemsandpsychicdistress,qualityoflife,working process,risksinherenttotheprofessionand/orconceptions onthesesubjects.Papers that relatedmental disorder to specificprofessionalclasses notpertainingtothe medical professionandtoanesthesiologistswereexcluded.
Twenty-sixpublicationswerelisted,andasoursisa theo-reticalreview,anassessmentofthescientificqualityofthe articlesselectedwasnotconducted.
Results
Briefdescriptionofanesthesiologist’swork
Studiesclaim thatthe working activityof the anaesthesi-ologistis characterizedby rapidand firmdecision-making in critical situations, in order to promote the necessary actions.8,9Ingeneral,theanaesthesiologistworksin
emer-gencyservices,inintensivecaremedicinescenariosandin thetreatmentofacuteandchronicpain.10 Itmustbesaid
thattheactivityofthisprofessionalisoftenpermeatedby stressfulsituationsthatrequireafullstateofreadinessand surveillance,8,9,11,12 considering that, evenif properly
fol-lowingthe anaestheticroutine,the anaesthesiologistmay have to deal with possible variability in his/her patient during an anaesthetic act.9 Consequently, it is clear that
theanaesthesiologist assumesgreatresponsibility to anes-thetizea patientfor amedical procedure, becausemany events(bothadverseandunknown)canoccur,requiring con-tinuousmonitoring.9
In describing the activity of anesthesiologists, we can mentionthetaskofmonitoringthevitalfunctionsofpatients inmajortrauma,cardiacarrest,emergencysurgical proce-duresandpostoperativeperiods.Theanaesthesiologistwork inthemanagementof conditionsthatthreatentheliveof patients,12andalsotoeasetheworkofseveralother
physi-ciansinthemanagementandcareofcriticallyillpatients.13
The anaesthesia is fraught with potentially stressful momentsinwhichtheanaesthesiologistmustdealinorder to continue his/her working activity without jeopardiz-inghis/herphysicalandpsychicwell-being.5Consequently,
someauthorsconsidertheanesthesiologyasaspecialtythat promoteshighlevelsofpsychicdistress,stress,work dissat-isfactionandevenburnoutsyndrome.6,7
Problemsofactivityoftheanaesthesiologist
Qualityoflife
Agroupofexpertsfromdifferentcultures,whocomposed the Quality of Life Group of Division of MentalHealth of theWorldHealthOrganization(WHO),definesqualityoflife as‘‘an individual’sperceptionof itspositionin lifeinthe context of his/herculture and system of values in which he/shelivesandinrelationtohis/hergoals,expectations, standardsandconcerns.’’14 Itwaswithinthiscontextthat
someauthors assessed the qualityof life of anesthesiolo-gistsfromstudiesconductedinthecitiesofRecifeandJoão PessoaandintheStateofSergipe(Brasil),withtheuseof the instrument/questionnaire proposed by WHO to assess qualityof life: WorldHealthOrganization Quality ofLife, abbreviated version (WHOQOL-Bref). In these studies, we arriveattheconclusionthattheexcessiveloadofworking hoursconstitutes a negativefactor for the qualityof life oftheseprofessionals,astheyhavelittletimeforrestand ansparingparticipationinsocialandleisureactivitieswith their families. Possibly this fact, coupled with the stress of the anaesthetic practice, induces the development of
physicalandpsychologicalproblemsthatmayleadtolosses inworkingperformance.15---17
Genderdifference
Regarding the difference in perception of quality of life between genders (male---female), it is mentioned that women had an overall assessment of quality of life sig-nificantly lower than men, including in psychological and socialrelationships’domains.15Studiesinvestigatinggrades
and components of working stress and burnout syndrome in anesthesiologists reported that women had higher lev-els ofstress and amore elevated frequency of symptoms related to stress compared tomen.6,18 This is very likely
to happen due to the accumulation of tasks of the mod-ernwomanand hergreatercommitmenttoissuesrelated toworkandfamily,whentheytakeadoubleoreventriple workload (work, home andfamily).15 Therefore,we must
emphasize the decisive entry of women into the labour marketandinspecificallyintheanesthesiologyareasince, culturally, thewoman shows greater tendency to become moreinvolvedwithissuesrelatedtofamilyandwork.This isanotherpotentiallystressfulfactorintheworkinglifeof femaleprofessionals.6
Causesofworkdissatisfactionandofmentaland behaviouralderangement
Accordingtosomestudiesdiscussingtheissueofwork dis-satisfaction, there areanesthesiologistsclearly frustrated withseveral ofits aspects.Someof them arethe lack of recognition oftheirprofessionalactivity,thehigh number of working hours and lack of regularity of worked hours, theworkingpatterndefinedbyotherspecialistsconsidering theteamwork,6,19lowwages,fewprospectsofprofessional
ascension,andadifficultorganizationofworktime.10
Thepoorcontrolovertheirworkismentionedasarobust cause of professional dissatisfaction by anesthesiologists. The variables related tothe strengtheningof this control have apositiveeffectonjobsatisfaction. Someexamples of these variables are the influence and participation in the development of tasks, in control of time and in the decision-makingprocess.Thus,theanaesthesiologistwould havemoreinfluenceoverthepreparationofhis/herscales and workflow. These aspects are essential to the work-ing organization,substantially influencingthe level ofjob satisfaction.10
Inthiscontext,authorswhoaddressthedemand---control interactionatworkclaimthatahighlevelofworking con-trolisaccompaniedbypositivehealthcharacteristics,while a difficulty in carrying out satisfactorily labour activities promotesdisturbances.20Anesthesiologistsconsideredasin
good physical and emotional health reported significantly greater working satisfactioncomparedtotheir colleagues reportingcomplaintsorphysicalandemotionalproblems.10
Thus, it followsthat theanalysis of work-related stresso-genic factors and their impact on health show that the decision-making power or autonomy (control power) are environmentalmoderatorsofstress.20
and workplace issues and responsibility and fear to harm the patient,7,18 besides the frequent work in an
‘‘anaesthesiologist on duty’’ system, associated with the concernsaboutfamilylife.18Alltheseproblemshavestrong
correlation with the development of stress-related symp-toms,andthesesymptomsareassociatedwithdepartures ofworkactivitiesbytheanaesthesiologist.18
Anotherexample ofa triggeringfactor of work-related stressisthenoisepollutionintheenvironmentofoperating rooms,evenatlevelsnotabletocausehearingloss.Noise emittedbymonitors,anaesthesiamachines,ventilators,air conditioners,surgicalinstruments,alarms,conversationand peculiaritiesofthesurgicalprocedurearecited.The expo-sure tonoise can causechanges in mood,interference in communication between professionals and attention and concentrationdeficits,and thushelp toincreasethe like-lihoodoferrorsduringworkingactivities.21,22
Moreover,theoccurrenceofunexpected criticalevents duringanaesthesiais anothersource of stressat work.7,23
Anesthesiologists report that the feeling of not anticipa-tionofaproblem,losingcontrolofa criticalsituation,or not knowing what is happening are commonly described asparticularlystressfulsituations. Incidentally,thisstress tendstoincreaseinsituationswheretheanaesthesiologist is responsible totrain other doctors in order to promote anadequate educationtoresidents,besidesnormally car-rying out their own activity.23 However, it is shown that
themoststressfulaspectsrelatedtotheanesthesiologist’s work are the interference of his/her work with family life, especially for professional women,6,15 as previously
mentioned,and timerestrictions.6,7,18,23 Thisis
character-ized as a pressure to quickly ‘‘get the ball rolling’’ at service,inordertoreducethewaitinglistandthusincrease theservice turnover,6,23 in association withinevitable
dis-placementsbetweenhospitals.6,19 Inaddition,thereisthe
fact that anesthesiologists are often urged to come to workearlytoevaluatepatientswhotheyhaveneverseen before, and induce anaesthesia rapidly without adequate pre-anaestheticinformation---situationsthatcause frustra-tionandstress andalsopsychologicaldistressarisingfrom workingactivity.6
Itwasalsoreportedthat,fortheanaesthesiologist,the longworkinghours’rhythmbecomesincompatiblewith fam-ily and social life, and this is exacerbated by the long travellinghoursinherenttourban lifeandbythevirtually unlimitedavailabilityoftimeinfavourofhis/herwork activ-ity,whichcancausemaritalconflict,withbrokenmarriages orunstablemaritalrelationships.Suchstatementsareissued byprofessionalsofbothgenders.19
Diagnoseddiseases(physical,psychicandbehavioural problems)
Various physical and psychic disorders related to anes-thesiologists’ working activity are citedin the literature. Studiesin differentcountriesshowthatthe mainphysical and mental problems related to job stress in anesthesi-ologists areemotional instability, irritability,hypertensive crisis,myocardialinfarction,nervousness,anxiety, depres-sion, gastric and duodenal ulcers, headache, abdominal pain,intestinalpain,exhaustion, feelingsof indifference, and memory and sleep disorders.7,18,19 In addition, some
authors claim that the work on duty system is the main causeofsleepdeprivationandrelateddisorders,including suicidality.18
Therearealsoreportsofahighincidenceofsleep disor-dersamongresidentsofseveralareaswhencomparedwith otherhealthgraduates.3Dataonassessmentofsleeplatency
inanesthesiologyresidentsatdifferentperiodsaftershifts, throughcontinuouselectroencephalogram(EEG)for recor-dingofsleepsignals,werepublished.Ashortersleeplatency wasdemonstratedinphysicianswhoseregularsleepperiods wereprevented byoccupational activity.Thus,it appears thatthereisahighriskofreducedattentionin anesthesi-ologyresidentswhoremainworkingafterseveralhourson duty,especiallyinascenarioofstabilizationofanaesthesia. Atthistime,theanaesthesiologistmustremainin continu-oussurveillanceandobservationofthepatientandmonitor machines.Thus, the periodof anaesthesiastabilization is a timeof greater risk for the tired and sleepless profes-sional,whograduallydiminishhis/herlevelofvigilancetill fallingasleep,breakinghis/herassistancetothepatientand contributingtotheoccurrenceofaccidentsinanaesthesia.8
Fatigueandstresshaveanegativeimpactontheworking performance of anesthesiologists,and these professionals arelesseffectivewhentheyaretiredorstressedduringtheir working hours.24 Therefore,the importanceof regulation
ofthe periodandof frequency ofwork ondutyfor these professionalsmust beemphasized,besides the numberof hoursofrestafterduty,toensurethesafetyandwell-being ofpatientsandofthephysiciansthemselves.8,18,24
Burnoutsyndromeinanesthesiologywasalsostudiedby some authors,by applyingthe Maslach Burnout Inventory (MBI),an instrumentconsisting of22 questionsrelated to the three components of burnout: emotional exhaustion, depersonalizationand reduced professionaleffectiveness. FromastudyinAustria,itisobservedthatanesthesiologists at risk of developing burnout syndromehave more physi-calcomplaints,greaterjobdissatisfactionanddifficultyof solvingproblemscomparedwithprofessionalswithout risk orsymptomsofthissyndrome.25Itisalsomentionedthatthe
indicatorsofemotionalexhaustionandofburnoutbecome moreprominentwithincreasinglevelsofstressandof pro-fessionalresponsibilityfortheanaesthesiologist.18
However,althoughanesthesiologistshavegreatchances ofsufferingthesyndromeorofexhibitingitsindicators,it wasfoundthatthereareothermedicalspecialtiesinwhich thepresence of burnout is moresignificant, for example, urologistsandoncologists. Thatis, althoughit is believed thatworkinginthefieldofanesthesiologyisastressfultask anda risk factor for occurrence of burnout, this wasnot confirmedinanAustralianstudy.6
Jobsatisfactionandcopingstrategies
Despitetheseveralnegativeaspectsofanesthesiology men-tioned, studies show that there is personal satisfaction from the practice of this activity. There are anesthesi-ologists showing high level of satisfaction, autonomy and commitmenttowork.7Authorsconsiderthat,amongsome
positive aspects, job satisfaction is a protective factor againstmentalillness,developmentofstressandburnout.6,7
ASwedishstudybasedininterviewsrevealedthe exist-enceofanesthesiologistswhowereveryfondoftheactivity theyperformed, without devising external obstacles toa goodjobperformance.These professionalshadreached a stateof adjustmentand adaptationtothemodeand con-ditionsofworkofanesthesiologistsandtotheirdifficulties andproblems.26Onemustbearinmindtheextreme
impor-tanceofdeveloping copingstrategiestotheproblemsand situations perceived as difficult in the daily practice of thisprofessional--- forexample, howtodealwithadverse eventsthatthreatenthepatient’slife.Inanotherstudy,the groupofanesthesiologistswhohadnopsychicsymptoms,for example,thoserelatedtoburnout,showedgreater auton-omyandthepossibilityofregulationoftheirworkingactivity andincreasedcontactandcommunicationwithcoworkers.25
Thecommunicationamongmembersofthesurgicalteam is considered an important form of strategy in order to endurestressfulsituationsoccurring in theactivity ofthe anaesthesiologistandalsotoavoid crisesandproblems in theworkplace.7,24,25,27Intheassessmentofateamwork,we
canconcludethattheworkingrelationship between anes-thesiologistsandsurgeonsarenotsogood,whencompared withother membersofthesurgical team,andthisis con-sideredasonemorefactorofpsychicdistressandstressat work.7,24
However,despite apossible lack ofprofessional recog-nitionamongsurgeons regardingthe anesthesiologists,all majorproblemscouldbeeasilysolvedwithagood commu-nicationamongmembersoftheoperatingroomteam.26
Thedevelopmentofthecognitiveabilitytounderstand certainsituationsascontributorstoacontinuousdaily edu-cation,insteadofsomethingthreateningtotheprofession, it’sanothercopingstrategyreportedinstudies.11,26 Thisis
away toreduce stress overload of anesthesiologists,26 to
theextentthatcriticaloradverseeventsduring anaesthe-siaareperceivedasmomentsofextremeimportancetothe acquisitionofprofessionalexperience.11
Agegroupandcopingstrategies
Some studies affirm that more experienced anesthesiolo-gistsget theability tobetter handlepotentially stressful situationsandworkoverload.Thisabilityisnotobservedin youngdoctorsworkinginthearea.9,25Itwasalsonotedthat
younger anesthesiologists have more stress-related symp-toms than older ones, more experienced in the area.18
Therefore, it is mentioned that the lack of total appro-priation of knowledge, associated with a possible failure ofsupervisioninresidency programmes,for example,may explainthegreaterevidenceofemotionalexhaustionandof burnoutfoundamongresidentsin anesthesiology,asthese do not have the necessary ability to deal with stressful situations.7Itisalsoobservedthatanesthesiologistsmainly
belongingtotheagegroupof31---40yearsareathigherrisk ofdevelopingburnoutsyndrome18andofexhibitingagreater
senseofjobdissatisfaction.10
It is important to emphasize the educational value of thediscussionofsignificantcasesandmajoreventsinthe professionalfield,asitencouragestheacquisitionof knowl-edgebytraineesandthemaintenanceofacollectivecare and prudence in the realm of anesthesiology.11 A study
conducted at Federal University of São Paulo (UNIFESP)
advocates the thesis that reducing stress during the resi-dency programmeshouldbeamajorfocusof thetraining process.3Thus,theobjectiveistofacilitatethelearningof
successfulcopingstrategiesarisingfromexperienced anes-thesiologists,tofosterthepersonalandprofessionalgrowth oftrainees,topreventprofessionaldysfunctionsand emo-tionaldisorders3,9 andto preventthefuturedevelopment
ofmental andbehaviouraldisorders,suchasoccupational stressandburnout.9
Theaccumulationofacquiredexperience,improvements in work organization, social support among colleagues6,7
andsharingworkwithexperiencedprofessionals6,24are
con-sidered other strategies for reducing the occurrence of conflictsandproblems intheworkplaceandconsequently of psychicdisorders,mental andbehavioural disturbances resultingfromtheanesthesiologist’sactivity.
Useofpsychoactivesubstances
Positivecopingstrategiestoreducetensionsarisingfromthe workofanesthesiologistsarenottheonlyonesmentionedin thestudies.Theuseofsubstancessuchascaffeine,tobacco, alcoholanddrugsisconsideredacommonhabitamongthese professionals,withtheaimofminimizingthetensionsand frustrationelementsoftheireverydayworkinglife.19Other
authors report thatthe large consumption of alcohol and drugsis alsomentioned asastrategytowithstandperiods ofstress.Andtheinterestingthingisthatthisperceptionis morereportedinrelationtopeeranesthesiologistsinstead oftheverypersoninterviewed.Thus,thereisdisagreement amongdata.6
AstudyconductedinSãoPaulocityrevealedthattheuse oflawfuldrugsamonganesthesiologistsispartoftheirjob routineandthereisa conjecture,inthe medical commu-nity, thatanesthesiologistsaredrugusers,considering the facttheneedofuseofthesesubstancesintheirprofessional activity,inthemanagementofpatients.Additionally,these professionalshaveeasyaccesstopsychoactivesubstances, afacilitatingfactorofdrugabuse.Hence,anesthesiologists have in theireveryday livesthe possibilityof usingthem; it follows that drug abuse becomes an easy way of eva-sionfortheirproblemsandpressures.Theanaesthesiologist seeksrelieftopsychologicaldistress,especiallyifthereis apredispositiontopersonaluse,whichaddsaconditionof depression,stressandjobdissatisfaction.28
However,thedruguseitselfisnotseenassomething rep-rehensible,wrongorcriminalinthemedicalfield,aslongas itdoesnotinterfereintheuser’shealthandworking perfor-mance.But,despitebeingatoleratedbehaviour,druguseis seenasadeviantpractice---somethingabnormal.Because of this,thedruguser does notassumepublicly thehabit; and thereis alsothe possibilityof promotingdetrimental effectsonbothprofessionalandpersonallevel.Allthiscan leadtostigmataandprejudicesagainsttheuser,whetheron thesideoflawlessness,onintheconceptionofthispractice asadiseaseoralsobytheimplicitrisksattheworkplaceand forthepatients’lives.28
knowledge tothe chief. Furthermore, thereis great con-cernaboutlimitingthereturntoworkofanesthesiologists whoalreadyhadproblemswithdrugs.Becauseoftheease ofaccess,thereisahugeriskforrelapse.28
Afurtherpointrelatedtotheconstanthandlingofdrugs intheanesthesiologist’sprofessionalactivityismentionedin aqualitativestudyconductedinMexico.Ithasbeenshown thatthecontinuousandrecurrentexposuretovolatile sub-stancesduringtheanaestheticactisharmfultohealthand maycausechangesinbehaviourandsociallifeofthe anaes-thesiologist.Becauseofexposuretotoxicsubstances,some authorsrelatedtheriskofconsumptionofthesedrugsand thedevelopment ofchronic depression, suicideattempts, sudden changes of humour, irritability, insomnia, fatigue, increased susceptibility to the use of antidepressants or stimulantsandincreasedriskofdrugdependence.Physical consequences of prolonged exposure to toxic substances, forinstance,immunosuppression,miscarriage, teratogenic-ity, leukaemia, lymphomas and libido disorders, are also mentioned.19
Conclusion
Bystudyingmentalhealthintheworkplace,itisobserved thatproblemsrelatedtotheorganization(valuationof func-tion, workload, rhythm, interpersonal relationships, rest periods,managementpressure,taskcontent,workedhours) arethepredominantcauseofpsychologicalproblems aris-ingfromworkingactivity.1 Fromthe informationobtained
inthisreview,variousaspectsoftheworkofthe anaesthe-siologistseemtobeimportantpointsforunderstandingthe relationshipbetweenmentalhealthatworkandwork orga-nization.Ingeneralterms,theorganizationalaspectsofthe workoftheanaesthesiologist,whichcanbehighlightedas illnessenhancers(fromwhatisexplainedinthisstudy)are thetemporalstructuringofthework,interpersonal relation-shipsandcontroloverhis/herownactivity.Moreover,there arenumerous quotations relatedto anesthesiologists’job stressanddevelopmentofburnoutsyndrome.
In the literature,thereis available informationon the increasingly common occurrence of burnout among physi-cians---aprofessionalfatiguesyndromewithanoverreaction to job-related stress.29 In burnout, the individual shows
emotional exhaustion, depersonalization, and ineffective-ness. In addition, factors such as inattention, neglect, cynicism, lack of empathy and hostility are characteris-ticsofthissyndrome,causingdifficultyoftheprofessional satisfactorilyperformingtheactivitiesforwhichhe/sheis responsible.
InFrance,theprevalenceofburnoutandassociated fac-torswereinvestigatedin978adultintensive caremedical unitsinpublichospitals.Ahighlevelofburnoutwas iden-tifiedin46.5%ofthemandthework-relatedorganizational factorswere stronglyassociated withthedevelopmentof thissyndrome. Acloserelationship between development of burnout and several points, includingthe poor quality of life of intensivists, work overload, hampered relation-shipsand conflictswithother colleaguesintensivists, was perceived.30 Thesefindingsaresimilartothosereportedin
studiesonanesthesiologists.
Furthermore, itis evident thatthe work-relatedstress isaverycommonrealityandthatcausesmanyafflictions.
Studies conducted in nine countries by Isma (Interna-tional Stress Management Association) point to Brazilians as among the most stressed people in the world in the burnout category, the most advanced stage of stress.31
It is also mentioned that stress is the main cause of behaviouraldisordersaffectingresidents,emphasizingthe importanceof the knowledge of data on this subject for the planning, organization and evaluation of residency programmes.32
Symptomsofanxietyanddepressionarecommonamong physicians, and ifthey do not deal adequately withsuch manifestations,somaticdiseasesbecomefrequentandmay encourage the abuse of drugs and alcohol and even may resultin suicide.Unfortunately,proposalsforprogrammes onmedicalcontrolinoccupationalhealthdirectedto physi-ciansand,particularly,toanesthesiologistswerenotfound intheliterature.TheRegulatoryNormno.32,whichlegally establishestheSafetyandHealthintheWorkplaceinHealth Services,has no specific determinations relating to occu-pational risks of the physician. Some authors suggest the implementation of a continuous and active psychological supportwithinhealthcareinstitutions,toimprovethehealth prospectsintheworkingroutineofphysiciansand, partic-ularly, of anesthesiologists.19 It is worth to mention that
suchameasureshouldnotoccurinisolation.Awholerange of preventive and occupational medical controls, notably regarding the ergonomic risks, especially those organiza-tionalones,isneeded.
Basedonthisliteraturereview,itcanbeconcludedthat theworkingorganization,ifnotappropriate,constitutesan importantoccupationalrisk factor forthelife andmental healthof workers,especiallyprofessionals focusedonthe careofpeople,whoareconstantlyexposedtostressfuland anxiogenicfactors.Giventhe informationobtained inthis study,wecansaythatthejobandhealthconditionspoint tothe need for changesin theanesthesiologist’s working organization.
Thus,itisexpectedthathealthinstitutionsandthe com-petent organs, especially the physicians themselves and theirclassorganizations,payspecialattentionto maintain-ingthehealthoftheiraffiliates/employeesingeneraland, inparticular,ofanesthesiologists---thefocusofthisstudy, withanefforttocontroloreliminatetheriskfactorsof occu-pationaldisease,inordertopromotemental andphysical well-beingoftheseprofessionals.Thus,the anaesthesiolo-gistwillbeentitledtoprovidehealthservicesofqualityfor patientsinneed.
may be points to be investigated and analyzed in future studies.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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