‘These are the duties of a physician: First… to heal his mind and to give help himself before giving it to anyone else.’ ~Epitaph of an Athenian doctor, 2AD
Resilience is that ineffable quality that allows some people to be knocked down by life and come back stronger than ever; the capacity to recover quickly from difficulties, often equated with toughness. Dean Becker, the President and CEO of Adaptiv Learning Systems suggests that ‘more than education, more than experience, (and) more than training, a person’s level of resilience will determine who succeeds and who fails. That’s true in the cancer ward, it’s true in the Olympics, and it’s true in the boardroom’. I pose to you, members of the AAS, that it’s also true in surgery.
Physician well-being is highly emphasized presently, with physician burn-out (aka ‘physician distress’) defined as a mental state characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. Burn-out poses adverse consequences for both patients and clinicians and has been attributed to 5 key drivers including: excessive workload, inefficient work environment/inadequate support, problems with work-life balance, loss of autonomy/flexibility/control, and loss of meaningful work. We care about burn-out because we care about our friends, our colleagues, our learners and our patients. Burn-out has clearly been linked to medical errors and complicates recruitment and retention into the field of Surgery (students, residents, fellows and faculty) with certain specialties more ‘at risk’ than others. Importantly, resilience may be predictive of resident and surgeon well-being.
There are a multitude of resilience theories that all share central themes incorporating 1) a staunch acceptance of reality, 2) an uncanny ability to improvise, and 3) a deep belief that life is meaningful. Importantly, resilience can be acquired and taught. As a current program director and major in the US Army Reserve, recently deployed to an austere base in Iraq, I think about resiliency a lot. I look for it in resident and fellow applicants, I try to cultivate it in my own residents and fellows, and I routinely look toward my own military training and Army mentors/leaders that regularly emphasize the importance of resiliency in daily routine.
In 2009 the US Army launched the ‘Ready and Resilient Campaign’ (R2C), a comprehensive plan to address the immediate and enduring needs of the ‘Total Army’ (to include active duty, reserve and National Guard soldiers; family and army civilians). The campaign continues to instill a cultural change by directly linking personal resilience to readiness and emphasizing the responsibility of people at all levels to build and maintain resilience. The R2C builds upon physical, emotional and psychological resilience to improve performance and the ability to deal with the rigors and challenges of a ‘demanding profession’. Sound familiar surgeons?
Embedded within the R2C is a 10-day ‘Master Resilience Training Course’ targeting non-commissioned officers and based on materials developed by the Penn Resilience Program that teaches the 6-core competencies of resilience: self-awareness, self-regulation, optimism, mental agility, identification of character strengths and building strong relationships. Within these modules, soldiers learn to recognize an activating event, their own beliefs about this event, and the emotional and behavioral consequences about those thoughts. Through army case studies they focus on explanatory styles and other patterns of thinking that can either heighten or undermine leadership, performance and mental health. They work to identify and overcome ‘icebergs’ or deeply held beliefs. A good example, and one commonly emphasized, is the belief that ‘asking for help shows weakness’. Additional modules focus on energy management (ie: meditation, controlled breathing, and progressive muscle relaxation), problem solving and strategies to avoid confirmation bias, minimizing catastrophic thinking, fighting back against counter-productive thoughts in real time, and cultivating gratitude. Soldiers are charged to identify character strengths in themselves and others, to look for patterns amongst the group and identify the ‘group strength profile’ and then focus on using these strengths to overcome challenges. Finally, they are encouraged to disseminate their training to their unit and project their own resiliency as leaders.
The American Psychological Association notes that ‘resilience is an ongoing process that requires time and effort and engages people in taking a number of steps.’ The American Medical Association has published online modules for physicians specifically to ‘foster stress hardiness and protect against physician burn-out’ by improving physician resilience and these modules echo similar concepts with a 6-step plan:
- Take a deep breath and get organized (for example: write down your personal mission statement)
- Think about your practice from a different perspective (for example: write down inspiring patient stories)
- Think about the big picture (for example: consider the legacy you want to leave behind)
- Find support and guidance from outside groups (peer support groups)
- Find meaning outside of work (for example: learn something new)
- Don’t forget to have fun
Half of all physicians currently self-report burn-out, a risk factor for depression, and approximately 400 physicians commit suicide annually. The reality of practicing medicine in today’s business climate of achieving service efficiencies by meeting performance targets brings many of the disparities between surgeons and their work setting into sharp focus. In summary, I charge you all to take note of your own resiliency, that of your colleagues and mentees, and cultivate it.
‘I don’t measure a man’s success by how high he climbs, but how high he bounces when he hits bottom.’ ~George S. Patton, Jr