Several years ago, I began to look at physician health in terms of understanding why some physicians appear to cope better than others in the same situation — why some are more resilient. I reviewed my practice population to identify dimensions of this quality that could be taught. My review produced “5 Cs of resilience”: confidence/control, connections, commitment, calmness, and care for self.
As a psychiatrist, I have worked with physicians in distress for 25 years. For most of that time, I focused interventions primarily on pathology: recognizing, responding to, and solving problems. Several years ago, I began to look at physician health from a different perspective to understand why some physicians appear to cope better than others in the same situation, that is, why some are more resilient.
It sparked a process to gain better understanding of what resilience is, the qualities of a resilient physician. Is it something different that they did or thought? Could it be taught? This new focus on resilience is proactive, positive, and offers primary prevention. It helps to recognize strengths and skills and offers an opportunity to develop strategies for success that build on existing capabilities. Top
Post-9/11, the American Psychological Association defined resilience as “the ability to adapt well in the face of adversity, trauma, tragedy, threats, and from sources of stress such as work pressures, health, family, or relationship problems.”1 Resilience is the ability to deal with difficult events, be flexible, bounce back, and grow as a result. It is a dynamic concept, an ongoing process that can vary over time.
As physicians, we have many stressors that we manage on a daily basis — in our professional and personal lives. Resilience is the ultimate life skill.
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I believe that resilience can be taught, so we can better succeed. Although universal agreement with this is lacking, some authors share this belief.3 Although some non-modifiable factors, such as our genetics, parents, upbringing, and childhood experiences, play a role in our current ability to cope through difficult situations, there are also many modifiable factors.
I reviewed my practice population to identify several dimensions of resilience that can lead to specific tools for cultivating resilience. My 5 Cs of resilience are confidence/control, connections, commitment, calmness, and care for self; they are described below. Top
A resilient doctor is a confident doctor
Confident people are those who have a positive view of themselves, their strengths, and their abilities, and are known to cope better during stressful situations. Developing such confidence and nurturing a positive view of oneself is possible and helps build resilience and a greater sense of personal control. Confident physicians have a healthy and positive self-image, and can balance the sense of inadequacy and self-doubts felt by many physicians4 with greater self-esteem and self-efficacy.
Self-esteem is the sense that we have strengths and can cope with what is going on in our life. Self-efficacy is our competence, our ability to learn knowledge and master skills, so that we can accept challenges, persist, and succeed. With the right combination of attitude and knowledge, in a time of stress or crisis, the confident person is optimistic and has the sense and belief that they can do it. As a colleague recently told me during an exceptionally stressful time, “While I don’t want to be going through this, I don’t question that I can.” Top
A resilient doctor is a connected doctor
Donald Winnicott5 first conceptualized the “holding environment,” which is the nurturing emotional environment that a “good-enough mother” provides to her child. The loving mother holds her baby, both physically and emotionally, is attuned and attentive to the baby’s needs, and nurtures it to form the basis for the child to learn to trust and grow. Expanding this concept, I realize that we need nourishing holding environments throughout our life, so we can continue to feel safe and grow. As we get older, these holding environments build resiliency and can be found within the context of our school, sports teams, friendships, relationships, and in our workplace. The key aspect of the holding environment is the presence of people who make us feel held. Top
The single most powerful predictor of resilience is the presence of caring connections with others. We need to create these relationships, both at work and in our personal lives, and then reach out to them regularly for help, support, guidance, and encouragement.
Kjeldstadli et al.6 looked at life satisfaction and resilience in Norwegian medical schools and concluded that the schools should encourage students to maintain their outside interests, friends, and personal lives. Jensen et al.7 explored the dimensions of family physician resilience and highlighted the value of supportive relations, which include positive personal relationships, professional relationships, and good communication. Lemaire and Wallace8 showed that support from spouse and co-workers as well as positive patient interactions are key factors in reducing stress and increasing well-being.
In our professional life, we must look for opportunities to build positive relationships —with our colleagues, medical team, staff, and patients. In our personal life, we all require a personal support system of partner, family, friends, and social and spiritual community. Such environments must be constantly nurtured. We need to allocate meaningful time for this, ensure regular communication, and be actively present. Top
A resilient doctor is a committed doctor
We choose to enter the medical profession because we want to make a difference. We took the Hippocratic Oath, promising to uphold professional ethical standards as we treat patients with spirit, diligence, and dedication. Having a continued sense of commitment to this cause allows us to face each day and persevere, especially at times when it is not easy to do so. This commitment to what we value and respect is key to our ability to be resilient. As long as we can feel that we are living fully and working toward meaningful goals, we are able to manage whatever is thrown our way.
In medicine, we must ask ourselves and constantly remember, “What drew us to this?” As we start working, it is easy to become too busy and lose sight of what was initially meaningful to us. Journaling is a way of telling and recalling our story. In her book, Kitchen Table Wisdom: Stories that Heal, Rachel Naomi Remen9 invites us to “listen from the soul.” Try it yourself! Sit with a blank piece of paper, and reflect. Ask yourself what made you decide to become a doctor? What now gives you meaning as a doctor? What story stands out in your memory as the best thing you have ever done as a doctor? Top
Although a vital commitment to our work is essential, this is even better extended to all aspects of our life. Ideally, we commit to life, to living fully and aiming for meaningful personal and professional goals. Victor Frankl10 describes his experiences in the concentration camps and explains how his sense of commitment to values and goals enabled him to survive such an experience. Once the things we do in our life make sense, we can more easily cope with the challenges along the way and sustain the sense of wisdom, wonder, and richness of life.
A resilient doctor is a calm doctor
We all know them — the doctors who manage to stay calm in the midst of turbulence and chaos. We wonder how they do it, as we become increasingly frustrated and reactive. For physicians working in highly complex situations, challenges seem to occur daily, and it is normal to have resultant thoughts, feelings, and emotions. Yet, the behaviour that can arise from such negative emotions is unhealthy for us, and often unacceptable to others. Top
Being calm includes two key factors: learning how to recognize triggers and times when things start to build up, and developing successful strategies for managing the associated emotions. None of us does this perfectly. During a quiet moment, take time to reflect what the triggers are, both at home and at work. It helps to have a range of tools to rely on as needed. There are many techniques we can learn to help ourselves remain calm, including deep breathing, cognitive strategies, such as reframing, positive thinking, relaxation exercises, journaling, and mindful meditation.11
Any of the above techniques can be effective in assisting us to feel a sense of calm at home and at work, but we have to practise. It is a process of learning and teaching our body what a calm state feels like and how to attain it. The more we do it, the easier it becomes. When practised regularly, these activities will lead to a reduction in daily stress levels and an increase in sense of joy and calmness. They serve as protective armour in the face of life’s challenges and give us the strength and energy to remain resilient. Top
A resilient doctor is a caring doctor
Caring for others is inherent in being a physician. This is what we do best. It is intuitive for us, we are trained to do this, and it is our role and goal. It provides a sense of meaning to our work, which helps to ground us during times of stress and crisis. Yet, caring for others is not enough; to be sustainable, it must be balanced with caring for ourselves. Top
Caring for ourselves is often less intuitive and definitely not part of our training. It is not our role; we are caregivers, not care-receivers. Thus, it is no surprise that this is not easy for us to do consistently. We put our own needs last, and, often, they are lost.4
A large aspect of self-care is taking care of our physical health. We are the only ones who can ensure that we eat properly, sleep long enough and restoratively, exercise regularly, keep our brains active, and have a family doctor and see him/her regularly. We can also monitor our emotional health, knowing and watching out for the signs of burnout.
Once you find activities that you enjoy, that make you feel relaxed and replenished, use the Tarzan rule to keep them going.12 Just as Tarzan swings through the jungle and does not let go of one vine until he has the other one in hand, do not stop and let go of a positive activity until you have one more booked! That way, you know it is going to happen again. Top
All of this requires that we give ourselves permission to care for ourselves. As a group of professionals, we are very conscientious and responsible, and often feel guilty when we are not working. We see time for ourselves as a luxury, as being selfish and focusing on ourselves when there is so much else to do. In fact, this is an investment; if we take a small amount of time and energy for ourselves, we are much more likely to be available to those who count on us.
Remember the airline safety demonstration: in case of an emergency, you are advised to put on your own oxygen mask first before you assist someone else. You are no good to anyone else if you pass out! This is an excellent reminder for our work in medicine; we have to stop and do the metaphorical equivalent of “putting our own masks on first,” especially in times of stress or crisis.
Resilient physicians deserve resilient medical systems
There will always be stress in the practice of medicine. Much of it is positive, healthy, and motivating. The desirable goal in assisting physicians to become more resilient is to have them build skills and energy reserves so they can continue to cope well in times of stress. Young’s modulus, from engineering’s solid mechanics, refers to the measure of the stiffness of an isotropic elastic material.13 It refers to the ratio of stress, with units of pressure, to strain. In medicine, although we are hoping to reduce the strain, we have no real “units of pressure” to measure the stress. As well, the stress comes from multiple sources, and varies depending on the physician, his or her specialty, and demographics; thus it requires multiple resources to manage. Top
Addressing the five components of resilience in an individual physician is like laminating a piece of paper. It gives it an extra coat, makes it hardier and more flexible. It will allow the physician to feel more empowered and confident to handle unforeseen and unpredictable events and, thus, can enhance the system. Yet, it is not enough.
As the situation in health care continues to progress with fewer resources and more stressors, we cannot merely respond by helping doctors just cope better and do more with less, or the system will not improve. As medical leaders, we must strive for a balance, one in which physicians feel more empowered to cope in difficult situations, and also have a voice and sense of control to identify and resolve problems constructively.
Enhancing physician resilience cannot occur in isolation. The relation between physician resilience and systemic resilience is complex and bidirectional. While we assist individual physicians to manage proactively in a healthier manner, we need system-level interventions too. Resilient physicians require and deserve a more resilient medical system in which to work. Top
References
1.The road to resilience. Washington: American Psychological Association. http://www.apa.org/helpcenter/road-resilience.aspx
2.Coutu D. How resilience works. Harvard Bus Rev 2002;May. https://hbr.org/2002/05/how-resilience-works
3.Seligman M. Building resilience. Harvard Bus Rev 2011;April. https://hbr.org/2011/04/building-resilience
4.Gautam M. Irondoc: practical stress management tools for physicians (2nd ed). Ottawa: Book Coach Press; 2011.
5.Winnicott D. Playing and reality. London: Tavistock Publications; 1971.
6.Kjeldstadli K, Tyssen R, Finset A, Hem E, Gude T, Gronvold NT, et al. Life satisfaction and resilience in medical school — a six-year longitudinal, nationwide and comparative study. BMC Med Educ 2006;6:48. http://www.biomedcentral.com/1472-6920/6/48
7.Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician 2008;54(5):722-9. Available: http://www.cfp.ca/content/54/5/722.full (accessed 1 Dec. 2014).
8.Wallace JE, Lemaire J. On physician well being — you’ll get by with a little help from your friends. Soc Sci Med 2007;64(12):2565-77. https://soci.ucalgary.ca/manageprofile/sites/soci.ucalgary.ca.manageprofile/files/unitis/publications/233-32724/well%2Bbeing%2Band%2Bphysicians.pdf
9.Remen RN. Kitchen table wisdom: stories that heal. New York: Riverhead Books; 1997.
10.Frankl V. Man’s search for meaning: an introduction to logotherapy. Boston: Beacon Press; 1959. http://streetschool.co.za/wp-content/uploads/2014/07/Viktor-Emil-Frankl-Mans-Search-for-Meaning.pdf
11.Bradberry T. How successful people stay calm. Forbes leadership blog. http://www.forbes.com/sites/travisbradberry/2014/02/06/how-successful-people-stay-calm/
12.Gautam M. The Tarzan rule: tips for a healthy life in medicine. Ottawa: Book Coach Press; 2011.
13.Young’s modulus. Tensegrity Wiki. http://tensegrity.wikispaces.com/Young%27s+Modulus
Mamta Gautam, MD, MBA, FRCPC, CPDC, CCPE — a psychiatrist with 25 years of experience treating physicians and physician leaders — is also a coach, author, and president of Peak MD, Ottawa, Ontario.
Correspondence to: mgautam@rogers.com