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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.
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Thank you. It is helpful to hear you are not alone and you can return to a better place and still be an effective doctor. Sometimes it is hard to see outside of your own fears and distress, and realise that there it isn’t only you who is having these issues
Geofrey – thank you so much for a thoughtful editorial. As a senior hospital based clinician that feels totally underwhelmed by existing support systems for senior consultants, I might take a copy of your very nice work for our Executive Director to read, the next time I visit him. Unfortunately, its more than 1 page long, and so its much longer than our required <1 page briefing notes. Regrettably, folk at this level appear to be only interested in advancing their own career ever upwards within medical politics, at the direct cost of their clinicians and their nowadays totally bruised feelings. Next time they talk about Q&S metrics in health-care, I might also raise the question as to why supportive environments for senior clinicians are also NOT so actively on the agenda, akin to the political agenda for our junior colleagues? This does NOT mean that I don't believe that our junior colleagues also deserve to be similarly supported. The 'pressure points' and how they are applied to us all, ie., our junior colleagues vs senior consultant colleagues, have all been turned around dramatically over the last 30+ years of my professional career.
A practical suggestion that might well help: perhaps some very basic 'human kindness' will eventually appear in the 'training manual' for hospital Executive Director's (esp. medically trained folk) in Australia? It can't do any harm, and it might lead to much better outcomes for both our patients and the medical staff working within our very stressed complex & busy health-care systems in Australia. It might also directly improve their own KPI's, that they so consistently nag us about achieving, again on their behalf, but almost invariably without the means to deliver in clinical practice.
Another practical suggestion: perhaps I should just focus on improving my golf swing to lower my handicap outside of work?
In essence: the currently overwhelmingly 'toxic' workplace environment is frequently becoming too hard to bear.
Hi Geoffrey,
Thank you for your honesty and telling of your story. I am sure you will get thoughtful advice about long term methods of becoming more resilient but I prefer to live in the moment as I think at least for now we are what we are.
I can recall a similar history to yours of the stress of medicine. On the one hand I do think caring doctors are the best and I for one can not change my character.I have seen other doctors who easily sail through situations with out any obvious distress and are able to make sound clinical decisions unencumbered by emotional attachment.
My solution was to act early and decisively when I sensed the pressure was too great. For instance after my student term in Pediatrics I gave away any thoughts of becoming a Pediatrician. I have taken long breaks five times from medicine altogether but gone back each time negotiating the conditions so that I can manage easily.
I know that it may not be possible to immediately opt out but a plan to do so asap will give you something to look forward too. You do not have to put up with harsh conditions. When I was doing my training in my specialty two Professors told me that not only would they ensure that I did not become a specialist but after they had finished with me I would not even be a doctor. They were wrong. I went overseas and felt valued.
I have always drawn strength from the most devastating situations some of my patients have found themselves in and yet how they have coped which has been humbling and inspiring . Sometimes I have wandered which of us was the patient. Good luck.
Hi Dr. Geoffrey
You are right. External support is critical in your profession and in many others. It is an inside-out-and outside -in approach involving you as an individual who feels and is always learning and as part of a team, organisation, community and society. Everyone should reach out and get support to avoid ruminating thoughts of negativity. I’m currently working on a research proposal on how compassion and self-compassion can help Doctors overcome adversity. It is a very complex construct which includes 5 components: suffering, noticing, empathic concern and effective action to help others and yourself. It is the action that makes individuals look for support when facing suffering. By evolution compassion evolved over the million years from mammals reproductive strategies of caring for infants and helping others. This behaviour is associated with increases in prosocial behaviours that is why a sense of community is crucial as well as with improved health and wellbeing. When you help someone you feel good. But the busy and hectic demands of Doctors erodes this capacity especially early in their careers. It will be interesting for me to validate this construct in this environment to demonstrate that feeling compassion can help ease the psychological burden of doctors but it needs to be supported by the organisational culture and systems. I’d like to talk more about this topic with you please email.
One of the steps that may help bolster our resilience is to identify and address deep-seated, ‘automated’ (ie. repeated) self-destructive thought and behavioural patterns which might stem from unaddressed past experiences.
A practical method is through supported instrospection and guided personal development, whether through a professional therapist or coach.
There are many external factors out of our direct and sole control; bullying and toxic work culture take more time and combined effort to alter. Accepting and addressing our own issues may improve our emotional and behavioural response to aggravating stimuli, resulting in increased collaborative effectiveness in the workplace. Bringing our new-found equanimity and awareness into our environment may be positively influential in a powerful way.
For some of us who believe we have it all sorted and see lack of resilience as a problem only for the weak, now would be the time for us to seek help. Hypervigilant narcissistic traits tend to be present in academics, doctors and etcetera, which may render us blind to our own behaviour.
It is everybody’s responsibility to ensure they are not contributing to a toxic culture through ignorance. Let us all accept and address our personal shortcomings individually, so we can be more constructive and effective collaboratively.
As an added bonus, we may actually find our personal life flourish as well.
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”
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.
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.
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.
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
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.
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.
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!
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?
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.
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.
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!