Doctors are resilient. Let's face it, you wouldn't have got this far if you weren't. Medical school and medical practice is grueling and we all have more than our careers to deal with. Discussions around individual resilience should not infer that the main of the issues around doctor wellbeing today is to be put back on doctors. Health care organisations must address their contribution to the issues that are faced in modern medicine. That means reasonable work hours and intensity, supportive education and mentorship programs, strong leadership and - importantly - senior as well as junior doctors taking care of the fire that burns inside of all of us.
However, understanding resilience and how to cope with the challenges that medical life presents us cannot be ignored. We all have to learn and grow.
What does resilience mean to you? When I first started thinking about this, it was a clear example of medical ‘anti-resilience’ that grabbed my eye. The satirical GomerBlog always tips the fine line between intellectual irony and uncomfortable truth. And their article ‘Optimistic, Bright-Eyed Med Students Eager to Transform into Jaded, Burnt-Out Physicians’ was spot on.
"Everyone looks forward to real-world medicine slowly 'breaking the souls' of those 'unsuspecting, foolish med students' and reminding them that the 'system is broke beyond repair' and that becoming a doctor 'was a huge mistake'.”
They eagerly wait for these aspiring medical students to spread their wondrous wings… and then crash and burn into a fiery, molten, but gorgeous mess of debt, despair, and regret.
“There’s nothing I want more than to become the worst version of myself that is humanly possible,” added Joseph. “Isn’t that what we all want for ourselves anyway?”
So what of resilience, and how can we avoid becoming that fiery, molten mess?
The term resilience is borrowed from the language of physics - the ability of a material to suffer stress or external pressure and to return to its original state, without becoming deformed once the stressor is removed. In psychology terms it refers to an individual’s capacity to resist adversity without developing physical, psychological or social disabilities.
It is widely recognised that excessive stress and burnout particularly affects doctors early in their career. Senior clinicians have usually developed resilience strategies to deal with the aspects of our work that cause the most anxiety. These stressful events include challenges such as high intensity workload, excessive bureaucracy, resource constraints, high patient expectations and complex ethical or moral issues. Proximity to death and repeated exposure to morally challenging situations can be a cause of distress if not managed actively.
Being resilient however isn’t about being indestructible - it's simply the capacity to deal with life events, to see problems as opportunities for personal growth, to recognise individual and collective resources and to continue to act ethically and responsibly. Strategies for maintaining resilience include self-reflection, creativity, humour and optimism.
Essentially, resilient individuals are able to recognise that they can have a positive impact on a situation, that some components of the ‘system’ can be controlled or influenced by one’s actions and that persistent effort is worthwhile. They also acknowledge that set-backs are inevitable and surmountable and do not need to cause excessive anxiety or withdrawal.
Dimensions of resilience established from published literature include self-control, self-efficacy, ability to engage support and help, learning from difficulties, and persistence despite blocks to progress (Howe A et al. 2012).
Considering the above dimensions and overall aims, I believe that to become resilient clinicians, we need to focus on 4 main areas of our lives:
- Self care and social support
- Reflective practice
- Professional support and debrief
- Personal growth
1. Self care and social support
A recent HBR article made the point: we often take a militaristic or ‘tough’ approach to resilience and grit - thinking of a marine slogging through the mud or boxer going one more round. But persistent effort doesn’t build resilience. One of the keys to resilience is trying really hard, pausing for a period of recovery and then trying again. Self-care encompasses a range of practices both during our working day and between work periods. If you want to build resilience, you need adequate internal and external recovery periods. Internal recovery is short periods of relaxation or time out of the day when you approach mental or physical exhaustion. External recovery is the time you make for rest between shifts and on recreation leave.
Where possible take time during the day to step away from the stress of your workload, have lunch with your friends, not while you do the discharge summaries or review results. Make sure you take all of your annual leave each year, and use the time to genuinely recover and build strength. Social support during both these periods is important and making time for creativity and non-medical activities that you enjoy will recharge you for your working week. Attention to diet and regular exercise is part of self-care.
Switching off can be difficult and if you just change your attention to political commentary or arguing with people on the internet, then your brain isn’t getting the rest it needs. We've all been in the situation where we lie in bed, unable to fall asleep thinking about the stresses of the day, finally waking the next morning completely exhausted. Rest is not the same as recovery. One of the most rewarding investments to relaxation & recovery is to practice mindfulness meditation. Just 10 minutes can quieten the chattering monkeys and reset arousal levels down several notches. Start with the mobile app Headspace.
2. Reflective practice
This isn't something doctors are generally very good at. Medical schools have introduced the concept into their curricula, but in postgraduate medicine it has failed to become established as a daily routine. Most of us do some type of reflective practice without necessarily labelling it as such. We learn through trial, success or failure, internal reflection on what worked or didn’t, and then consideration of how to do things better next time. Most medical Colleges have a reflective practice tool that is based around the 'What?, So what?, Now What?' model (RACP, RANZCOG examples & templates here). This is a semi-formal approach that encourages doctors to spend a brief amount of time each week reflecting upon what went well at work, why that might have been and how challenges might be overcome in the future.
The reflection should include not only task-orientated or medical skills, but also the domains of team working, relationship management and learning style. This lends itself well to the use of a journal to record the activity and this can be held on a mobile or desktop device - preferably one that syncs. Example apps for this include Evernote and Day One. There is good evidence that regular journaling brings positive benefits. Even if you don't use a template, simply write down one or two things that went well each day and reflect on your motivations for being a doctor. Very quickly you will realise just how much you are able to positively influence the lives of others, and ultimately draw on that perspective to help you withstand the challenges that inevitably come your way.
3. Professional support and debrief
It is critical for doctors to receive feedback on performance and development. We need to understand where we are succeeding and where to direct our efforts for improvement. Junior doctors change work teams frequently and this is a serious barrier to quality feedback. It is important to have both short and long-term mentors to support you. If you are on a 10-week rotation, hopefully by week 2 you will know who can support you and give constructive feedback. Set up a regular meeting, even if it’s over coffee once a week or fortnight. Talk through current challenges and review how your work is going.
When ethical, moral or emotional challenges occur, talk them through with your colleagues and mentors. Sense-making conversations about these ’soft’ issues are an important way to avoid the build up of emotional stress. Medicine is full of situations where ethical norms are challenged and we all need to work through them. Where many members of a team are involved, ask seniors to facilitate a multidisciplinary team debrief.
4. Personal growth
It’s easy to fall into the trap of believing that medicine has all the answers. We've all been on a similar conveyor belt of medical training for many years. When we look outside our profession or immediate area of expertise, the change can be refreshing. We all own mental models - a prism through which we view and make sense of the world. Don’t get too attached to what you believe to be true - more often than not a new perspective can bring rewards, both personally and professionally.
For me the areas of personal growth that are important include self-reflection, understanding and strengthening emotional intelligence and competencies in the area of writing, leadership and mentoring. My current wider reading includes books and blogs of Scott Young, Cal Newport (my review of his latest book), Brené Brown (videos: the power of vulnerability, shame and latest book), Harvard Business Review and books and writings from The School of Life. When I come across articles that are of interest I export them on my mobile directly to an Evernote folder for later review. Here’s my current Personal Development Inbox. Make a start on your own wider reading in areas of personal growth that are important to you and you’ll find it helps at work too.
As doctors, every one of us is in a position of leadership. Even if we don’t have immediate ‘reports’, we mentor medical students, we take the lead in relationships with our patients and we have leadership roles in multidisciplinary teams in theatre, on the ward and in other areas of our practice. How are you helping nurture resilience in those around you? We need to work on our own, teach those around us and bring resilience into our workplaces to build heathy teams.