During a recent run-in with burnout, my co-resident at a large teaching hospital in Boston proposed several small but tangible changes that would significantly improve her life as a physician, things like getting help with retrieving outside hospital records, securing prior authorizations for certain medications, and scheduling follow-up appointments at discharge. She was instead reminded that “these things are a part of our job, and we need to explore why everyone else is doing them fine and you are getting burned out because of them. For any line of work, you have to learn to cope with the negatives.”
She would feel better, she was told, if she could “be more resilient in difficult situations.”
What a load of nonsense.
Resilience is a favorite buzzword in the crusade against physician burnout. As two University of Rochester physicians describe it, resilience is “the ability of an individual to respond to stress in a healthy, adaptive way such that personal goals are achieved at minimal psychological and physical cost; resilient individuals not only ‘bounce back’ rapidly after challenges but also grow stronger in the process.”
There’s no question that resilience is a central element not just of physician well-being but of human well-being. Overcoming obstacles and emerging seasoned and stronger stimulates personal growth, a key factor in overall fulfillment.
But to physicians who grapple with burnout, the “solution” of boosting resilience falsely implies a baseline deficiency of it. Anyone who has made it through medical school and is working as a physician has demonstrated ample resilience time and again. So the prescription of more resilience is not only hollow but insulting.
Now that I’m in the final year of my residency, I recognize that my sometimes overwhelming training has made me not only a competent physician but a more capable professional and person. Beyond the challenge of acquiring knowledge and learning clinical decision-making, the residency process magnifies many of life’s challenges: a lack of control and predictability; constantly changing teams, roles, and expectations; rapidly learning new skills and lingos; dealing with shifting schedules and unkempt workspaces; and constantly being tossed into unfamiliar and uncomfortable situations. As it turns out, the skills required to withstand, adapt, and overcome such difficulties are also extremely useful for thriving in this turbulent world.
Rather than viewing these stresses as sources of burnout, a more productive approach would be to reframe them as opportunities to develop more self-awareness, better emotional regulation, healthier routines, and restorative practices.
What we need to do is make this hidden curriculum of medical training more explicit. The training system should take these life lessons, ones we hopefully recognize in hindsight, and make them direct learning objectives from the get-go. The hospital, with its unending distractions, unforeseen mishaps, uncontrollable workflow, unbelievable suffering, and unhealthy environment, is perhaps the perfect training ground to practice these relevant and transferable life skills.
Such formal training is sorely lacking. We now merely hope that the struggling trainee will “hang in there,” “tough it out,” “beat the burnout,” and somehow emerge stronger and more resilient on the other side. That is a failed strategy.
To transition from a hidden curriculum to an explicit one, we would first need to provide the requisite resources. To build resilience, individuals must first recognize when they are being harmed by stress and then discern the difference between adaptive and maladaptive reactions. Just like discerning heart sounds or interpreting electrocardiograms, this demands deliberate practice.
Along with studying questions for board exams, we should be practicing visualization and mindful breathing techniques, answering reflective questions to foster self-awareness, and engaging in positive self-talk. In addition to reading “Harrison’s,” the bible of internal medicine, we should also be reading books like Carol Dweck’s “Growth Mindset,” Angela Duckworth’s “Grit,” or Marcus Aurelius’ “Meditations” to hone our personal philosophies and values.
That’s a start, but it alone is insufficient. The burden for change mustn’t rest solely on the individual. It’s unreasonable to expect a trainee who is feeling isolated, exhausted, and depressed to repeatedly muster the emotional energy to reframe adversity into a growth opportunity. Proper training involves coaching concrete skills and strategies that shrink the gap between actual and desired performance.
In the Professional Development Coaching Program, developed at Massachusetts General Hospital, trainees learn creative ways of problem solving by strengthening adaptive thought patterns. This program reduces burnout. It should be a national standard.
We also need dedicated communities in which people share similar struggles and collaborate to support each other’s growth as individuals and as a collective workforce. Amorphous support groups won’t cut it. Instead, formal Balint groups — purposeful, regular, facilitator-led sessions among physicians to support personal and professional development — have been shown to increase participant resilience, job satisfaction, and patient centeredness. Adversity and struggle provide fertile ground in which to cultivate deep human bonds. As physicians’ work becomes increasingly digital, we should be doing everything within our power to connect not only with our patients but with each other.
Training in medicine is often likened to training in the military — an all-consuming, pressure-filled process that breaks you down and builds you back up. The difference is that this kind of personal growth is core to the military’s mission, but not to medicine’s. U.S. soldiers now participate in a formal Comprehensive Soldier Fitness program, a key component of which features Master Resilience Training. Based on research showing that resilience can be measured and learned, this training program helps leaders cultivate and teach resilience by building mental toughness, signature strengths, and strong relationships. A proactive strategy to prevent post-traumatic stress disorder, this curriculum has been called the “backbone of a cultural transformation of the U.S. Army in which a psychologically fit army will have equal standing with a physically fit army.” More than 95 percent of participants attest to using these skills both on the job and in their personal lives.
As the military understands, and as medicine has yet to grasp, resilience demands a dedicated curriculum and supported practice engaging with — not withdrawing from — a harsh reality.
This fall, results from a survey of 4,000 resident physicians nationwide across various specialties showed that almost half are burned out and nearly 1 in 5 regret their career choices. It does not appear that “everyone else is doing [our jobs] fine.” Yet we persist in placing the locus of disturbance on the individual.
Advising a physician experiencing burnout to become more resilient without a clear action plan and proper supports is misguided at best, and likely to be harmful. Physicians who recognize their current limits should be praised for safeguarding their own health and that of their patients. Resilient physicians acknowledge their limits, uncertainties, and errors in the interest of sustaining their professional competence and sense of well-being.
In the business literature, “organizational resilience” describes the ability of an organization or system to anticipate, prepare for, respond, and adapt to incremental change and sudden disruptions in order to survive and prosper. Systems display organizational resilience by innovating and investing in their leaders and work force.
In medical training, the evidence speaks for itself. The work force is discontent. This system is ripe for disruption. Let’s see if it displays as much resilience as it expect from its trainees.
Rich Joseph, M.D., is a resident in internal medicine at Brigham and Women’s Hospital in Boston. The ideas expressed here are his and do not necessarily reflect those of his employer.
Yes, the “resilience” stuff is insulting and demeaning, especially coupled with an explicit determination NOT to improve work conditions. Thanks for your great article.
Bravo! Richard you are an excellent writer and an insightful and evolved young man. You WILL be an excellent physician but think you will more importantly be a shaker & mover in our archaic medical system.
Keep thinking—keep speaking out, your colleagues and our nation need more humans like you. Aloha & Mahalo
Resilience is based on Martin Seligman’s positive psychology nonsense. Seligman was instrumental in the US’s Torture Program. He used social media and a cadre of true believers to peddle this false Ideology, like a multi level marketing program. Seigman’s career started out with torturing homosexual youths, he believed that applying electrical shocks could alter sexuality. His distorted world view, based on torturing dogs with electrical shocks to create “Learned Helplessness” is the basis of all of his work. There is No scientific evidence any of this benefits anyone. The basic platitudes he uses, are vague and generally beneficial. Not one of these peddlers has considered the possible adverse events associated this this terrifying world view. They used Resilience to justify the mistreatment of children, resulting in more suicides, deaths and despair. We have fallen down the rabbit hole, Seligman’s altered worldview is contributing to misinformation and a fact free version of reality.
The Facts and Data paint a much different picture, but testimonials amplified on social media, by people with a financial interest in this nonsense, have made this appear fact based.
Physicians are burning out, because the current corporate health are model is not what they signed up for. The suffer moral injuries every day, like soldiers. Seligman found a way to silence guilt, revulsion, and morality. Resilience does not mean what you think it does. It means that empathy and common sense are a weakness, and only entitled people from comfortable backgrounds who are able to ignore the results of their actions can succeed. They created an alternate world view where the “resilient’ are the ones psychologically incapable of understanding the harm they are perpetuating.
Psychopathology is now the norm!
I am not familiar with the author that you are citing. However, based on your description, we have to deny all of the medicine, as almost all of it based on prior mistakes. Remember beta-blockers for MI used to be malpractice, not giving xigris for septic shock etc. resilience is a good quality in any life situation which may be improved. The need for resilience however, in our profession may be unjustly imposed, since as a doctors we should know how to diagnose and treat, not how to deal with documentation, legality, EMR etc. as we all live in real world we cope with all that staff, but it should be administration’s and legal system understanding that it is not our primary role (not that they care, of course)
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