WHEN I was battling the demons of severe depression and suicidal ideation, the word resilience was mentioned … well, more stated at me.

You’re just not resilient enough … if only you were stronger … you’re just not able to cope … you know not everyone is cut out to be a doctor … have you considered another career? … you are too sensitive, too self-reflective, that’s your problem.

I was a 20-year plus veteran in the profession however. A little late for this advice, although I had considered a career change in order to save my own life. It was far better to be alive and see my children grow up than return to the very place that was destroying me.

Junior residents experience this from senior doctors still today – “it’s what we went through, what we had to put up with, therefore, so should you”.

At the time when I was deeply unwell, they were not the words of support I required at all. What I needed was the opposite, but the blame had been clearly laid at my feet. I was the failure, it was not the system I was in. The system was failing to accept some responsibility.

So preoccupied was I with this concept of resilience that I even got a tattoo as a permanent reminder of what I lacked or thought I lacked. It’s now a reminder to me that I am resilient and I was at that time.

What is resilience? The word is thrown around a great deal these days – I would suggest a little too often in medicine.

Derived from the Latin word resilio – to rebound, bounce back, recoil – in modern terms, resilience may be viewed as the ability to bounce back from adversity.

The school my children attend uses this word often – its importance in future life, the avoidance of being what they call a “helicopter parent”. In this environment, resilience is built in a supportive community, with family support that is loving. It’s this connection – the sense of belonging – that is important. Resilience is not the domain solely of the individual but is a shared process. Resilient children develop this skill with a sense of control over their lives. They can learn from failure, that they matter as human beings, and that they have strengths that are valued.

Sharing adversity is also important. As the saying goes, “in prosperity, our friends know us; in adversity, we know our friends”. The recent acts of terror, both here and overseas, rather than breaking communities apart, have only strengthened them. It’s the bonded community and individual resilience that has developed.

What about my resident years, early on?

This will not be much different to that of many others. I still recall my first Christmas day at work in a country hospital. Not only was I at work and largely alone in an emergency department but I had to deal with the death by road trauma of a young child. I remember it every Christmas, as that family’s day will never be the same again. There were long hours, poorly supported rotations, on-call, sleep deprivation, fear of making mistakes – all of which is all too familiar to any doctor.

A friend of mine, a retired police detective, said to me the other day that it wasn’t the first rape victim, or gun drawn on him, but the accumulated many moments that eventually make your cup overflow. The analogy holds true in medicine. The long hours, the on-call with sleepless nights, the need to turn up at work the next day notwithstanding, unsocial hours, compassion fatigue, burnout, the increasing fear of litigation, the difficulty in maintaining connections outside of work, the increasing violence against health care workers and the increased workplace bullying are familiar to us.

These are coupled now with the top-down targets, both time and fiscal, often set by individuals that rarely set foot in the clinical domain.

Medicine takes a bright group of people who are caring, self-reflective and sensitive – is this not what one requires in a doctor? – and places them in a hostile and increasingly unforgiving environment. The result is an increase in mental health issues, especially in that first year of residency. It’s hardly the place to thrive rather survive, and where does that leave the very people we wish to look after?

In all my years in medicine, I have learned very little from the very people that demand resilience of me.

I have spent many hours in therapy, using self-help and other means to enhance my strength toolbox.

These things are partial help, however, because the environment I am in still does not allow for bouncing. It’s far easier to bounce on a trampoline than concrete, and medicine has too much concrete.

The development of resilience is not just the domain of the individual, or the worker in the health care system. It’s a community effort, within the micro- and macro-environment in which we work. It requires connections, both social and professional. It’s so much more than a seminar or workshop, or another PowerPoint presentation, and much more than a simple platitude about doing more.

As humans we seem to be hardwired to see disaster and bad things, and this is so much more evident in doctors. We are too often good at delivering criticism to our peers, but not giving praise or support. For the leaders who are reading this, reflect on your past few interactions.

My daughter, who recently dislocated her finger, required a hug not some resilience-building exercise, reassurance that she would be okay. This is better than saying “suck it up”.

I consider myself very resilient; in fact, the evidence is that most doctors are.

Outside work, I have completed some of the world’s toughest ocean swims. My resilience has not been questioned in the water, but it’s developed with a strong team around, a sense of support that if I get into difficulties, I will be okay. That allows me to push to the extremes and beyond. I used performance psychology and hypnotism to enhance my performance and deal with setbacks. Most, if not all, elite sports people use them. Why not medicine?

Resilience requires health professionals to have and feel a connection, a sense of belonging. It requires a system that allows one to learn from mistakes without fear of reprisals, but with positive suggestions about how to improve. It requires systems to develop individual signature skills and work on deficiencies. It requires positive peer support, and realistic goal setting, especially around time and money. It needs to help doctors learn the skill of asking for support, and then support them when one does. It needs to give doctors room and time to allow resilience to develop – down time, exercise, outside connections and rest, with adequate sleep.

I know from my own personal point of view that I have worked very hard to enhance my strengths. In fact, a major step in my recovery was to stop blaming myself and protect myself from the system’s issues. I now ask for a system that better allows me and others to bounce.

We are still a long way away from this.

Dr Geoffrey Toogood is a cardiologist and a long time advocate for mental health. He has swum the English Channel. He came up with the idea of crazysocks4docs day.

If this article has raised issues for you, help is available at:

Doctors’ Health Advisory Service:
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Tasmania and Victoria … 03 9495 6011
WA … 08 9321 3098
New Zealand … 0800 471 2654

Lifeline on 13 11 14

beyondblue on 1300 224 636

 

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.

 


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12 thoughts on “The resilience myth in medicine

  1. Anonymous says:

    Doctors are the enemy of the doctors! There are exceptions I must say.
    A junior doctor, felt sick while on roster (and finished all the work that were to be done in the never ending environment). Requested the senior registrar to leave on time over phone; perceived as pretending! Asked to do some more work for the senior and then can leave. On the way home quarter hour later vomited in car while driving rescued by mother! Hope we do not have to face the doctors who can not read the face of a sick person nor try to help others even another doctor! All of these accumulates and create further problems. Shame!

  2. Fernanda Claudio says:

    Good article and deeply felt. I agree that the resilience approach has been overdone and overused throughout our educational system and work spaces. I also think that the most obvious failure of the resilience approach has been the invalidation of the sufferer’s or victim’s experience and the insistence that the individual recover or “bounce back” from circumstances of brutality wrought by institutions, systems, other individuals, and events. The resilience approach can negate the fact that nefarious circumstances produce damage to individuals and that those circumstances can be made by institutions. I have seen resilience overplayed in schools where there is bullying, and in higher education where there is poor resourcing for help and poorly planned programmes that foster anxiety. Maybe Australian medical schools should take a leaf out of the experience of McGill University in Canada that includes mindfulness in its MD program.

  3. Anonymous says:

    thank you for insightful words
    I think personal resilience is our backbone hopefully nurtured from childhood. The training and doctoring is traumatic, the ongoing patient crises we do and should feel and then our own life issue come into play. Yes, my colleagues PLEASE do not persist in a career if doing so will lead to your suicide. But there is such room for compassion and kindness in medicine ( and my field of surgery) well before a crisis point is reached. The hierarchy in public hospital surgical doctoring is a deep seated (born and bred, mostly male) entitlement of self professed brilliance, blame shifting with junior doctors as scapegoats and protection of destructive, cruel and nonprofessional behaviour by being in a ‘safe’ position of leadership. And now medicine has become more competitive it will just get worse. We used to loose our junior doctors to dying from fatigue while driving from long shifts, now they are so distraught they end their lives and the training college’s response is to document a few cases studies of individuals experiences, like a callous side show. Yes RACS, you may be aware but what are you DOING about it. I suggest touching base with your medical students they will give you a true insight into how the ‘system’= real surgeons treat them. Operating with Respect mission statement campaign is not worth the paper/hard drive it is written on, but it must provide a good laugh in the boys club on a Friday night.

  4. Bruce hocking says:

    Geofrey – thank you for a superb and thoughtful editorial. I wonder if you could extend your thoughts in a further editorial regarding how we could better approach our patients in similar situations?

  5. Erin says:

    Thank you for such an insightful article that echoes so many of my own experiences and emotions on the subject(s) you discuss.
    The concept that reliance “training” is a responsibility of the individual is one that absolves the larger community around the individual of any responsibility in their failure to ‘bounce’ and
    Cliff Reid from Sydney HEMS talks often about multi-disciplinary team-building and training as you fight – we aren’t meant to be fighting one another for supremacy or fighting with our organisations to legitimise our humanity as doctors or nurses or ambos, etc.
    We are fighting against what is possible and yet another impediment to our success as organisations is a lack of shared responsibility for the resilience and redundancy planning of the organisation as a whole.
    Personally, I think resilience in our profession starts by realising that we are all replaceable. As soon as we perceive ourselves (or imagine others perceiving us as) irreplaceable, then we are unable to justify self-care (at the short-term expense of time worked), nor can we adjust our workload to fit with life. Life throws all sorts of things at us and we marvel at how our patients cope with adversity – we need to take some of our own advice!

  6. Andrew Nielsen says:

    Yes, the whole resilience thing is overdone. Teachers says some revolting things in that context.

    You already know this, of course, but by hugging your daughter you increase her later resilience. She carries around a little version of you in her head. Later, when things are bad, she will give herself a hug.

  7. Anonymous says:

    I think this really hits the mark, and it applies across life, not just in medicine. For example I get very frustrated reading about approaches to childhood bullying which focus almost solely on ‘standing up to’ the bully and on resilience as an individual skill, when the reality is that you are only able to do that if you have a solid foundation of self worth and the secure base of knowing that others have your back. Approaches which are intended to ‘toughen up’ victims can have completely the opposite effect, and supportive approaches which are often dismissed as mollycoddling will often help to build the confidence to be able to stand up to bullying more easily. And as you point out, resilience has its limits. Repeated trauma may overcome the best of us.

    And most importantly, the secure base and sense of community MUST be based on reality. It is so easy for friends and colleagues to say after the fact (of a suicide or breakdown) “if only they’d reached out for help” – the reality is that often the person has tested the waters in many small (and sometimes large) ways to see if their request for help is likely to actually be met, and decided it wasn’t. After a while you give up and don’t bother asking at all. Or there is a sense that help is rationed, that you can only ask so many times, and so you hold out from asking just in case things get worse and you might need the help more at some point in the future.

  8. Andrew Watkins says:

    Resilience factors are important , they are often the reason why two individuals experiencing ‘similar’ ( note the caveat ) trauma may have rather different reactions, so it is a valid and important area of study.

    “Resilience” as a mantra in HR or College training programmes is, however, problematic, as it shifts the blame to the victim/sufferer – “you just have to toughen up” and shifts focus away from the environment that has caused the problem. As noted, it is often the chief perpetrators who use just this formula.

    The demands we place on ourselves and our juniors are insane, not helped by other external pressures.

    As paediatrician I am reminded of the child abuse dynamic – the abused child becomes the perpetrator in the next generation and then his kids do it with theirs who perpetuate it further

    We must be able to do better than this

  9. Robyn Seth-Purdie says:

    Resilience can usefully be considered as a product of developmental competence – the ability of an individual to meet a challenge commensurate with the level of knowledge, skill and degree of emotional self-regulation they have acquired. This applies to a professional in training just as much to an infant learning to take their first steps, to an adolescent forming a sense of personal identity, or to a young adult learning survive away from home.

    Developmental competence is sequentially acquired – and failure to master the essentials of an earlier stage will compromise the development of later stages. The developing professional and the developing child need support to master challenges, particularly those that stretch them to – but not beyond – the limit (see Anne Masten’s (2014) account of the research on resilience – ‘Ordinary magic: resilience in development’ ).

    Presenting a series of challenges that exceed the developmental competence of an individual will result in chronic or toxic stress. McEwen et al (2015 – Recognizing resilience: Learning from the effects of stress on the brain) warn that brains subjected to chronic stress may demonstrate permanent changes to gene expression, so that, notwithstanding functional recovery, a pre-stress configuration is never regained. Capacity to tolerate further stress may thus be impaired.
    Resilience is not a virtue that can be assumed by an act of will – but rather a function of an individual’s developmental competence in the environment that tests and extends it, while providing strong support. An individualised system of graduated and supported exposure to increasing challenge would represent the best type of training system for protecting staff from chronic stress, and patients from over-stretched and traumatised staff.

  10. Ian Truscott says:

    To be determined enough to swim the English Channel, yet aware enough to pen this great article – I’m impressed.

    It seems to me (& your message) that support by colleagues, especially senior colleagues, is the most helpful action to take, for doctors struggling…..before things deteriorate. Support mainly by just listening. And encouraging. Perhaps some action or advice.

  11. Anonymous says:

    It’s so refreshing to hear these words come from a senior clinician instead of the usual “harden up princess”, “back in my day etc”, “oh come on, it’s good for you” rubbish. In the past there was far less bureaucracy, far fewer treatment protocols let alone their side effects, so much more respect for doctors, no bed managers roving around shouting at you, let alone the turnover rates…thankyou Dr Toogood.

  12. Randal Williams says:

    I think resilience is the result rather than the cause i.e. you gain resilience by realising that you CAN overcome adversity and traumatic events, seeking help where needed. But this takes a bit of life experience. I tended to cope by reflecting on situations where I had been able to get over a difficult situation, and adopting the old biblical aphorism “no matter what it is, it will pass”

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