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Resilience is hard to define and examining the topic can raise more questions than answers
Am I the only one who finds the recent emphasis on resilience in doctors a little phoney? Especially those articles expounding how our resilience can be improved, if only we would work on it. It’s almost like some commentators think that the current wave of burnout among doctors is self-induced. Try telling that to the many doctors who have found a better working life in Australia and Canada, where the health systems look after their medics in ways Ireland and the UK have forgotten how.
In an effort to counter my growing frustration and a nascent cynicism, I decided I’d better look up some research on medical resilience. A review published earlier this year in the Postgraduate Medical Journal seemed like a good starting point.
A group of doctors from Northern Ireland carried out a systematic review of resilience in medical doctors. They found some 24 studies worthy of inclusion: These focused on demographics, personality factors, organisational factors, social support, leisure activities, overcoming previous adversity and interventions to improve resilience.
Derived from the Latin word resilio — to rebound or bounce back — one definition of resilience states that it is the ability to adapt well in the face of adversity or significant stress, even returning stronger afterwards. However, one systematic review concluded that there was no universal definition for resilience in the literature. Instead, the authors of this review identified five themes used to define resilience: Rising above adversity; adapting and adjusting; resilience as a dynamic process; ‘ordinary magic’; and mental illness as a marker of resilience.
Now, at this point my nerve endings began to jangle a bit. ‘Rising above adversity’ and ‘ordinary magic’ are not good starting points as far as I am concerned.
However, like a good hack and conscientious doctor, I ploughed on.
Eight of the studies found that demographic variables (such as age, gender or marital status) had no influence on resilience scores. One study of rural general practitioners in Australia found that the oldest group of doctors (aged 52-to-61 years) had higher resilience levels.
One would expect personality type to be relevant. Across the studies in this review, resilience had a strong relationship with personality traits that support high functioning in a demanding environment.
A study of New York physicians and a separate study of Australian general practitioners found that doctors with a higher tolerance of clinical uncertainly were significantly more resilient. Resilience was most strongly positively correlated with high self-directedness and strongly negatively correlated with harm avoidance.
In studies of paediatric and surgical residents, high levels of resilience correlated with high levels of self-compassion and mindfulness. The authors of those studies concluded that mindfulness is a potentially modifiable personality trait that is associated with resilience and is protective against stress.
Hmm… mindfulness is “a potentially modifiable personality trait”. I wonder. Anyway, moving along to the section on interventions to improve resilience, the authors identified five interventional studies that aimed to improve doctors’ resilience and that also assessed the influence of an intervention on resilience.
Resilience-building interventions took a variety of forms. The majority were delivered in group settings to trainees or residents over a number of weeks. Three out of the five interventional studies encouraged mindfulness or involved mindfulness-based interventions. The general aim was to cultivate a clear-thinking mental state. Two studies focused on self-care skills training combined with cognitive-behavioural and solution-focused counselling in psychiatrists and surgeons.
So what was the outcome? All of the research used validated psychological tests to measure resilience before and after the intervention. But only the self-care skills training programme in psychiatrists and surgeons identified a significant improvement in resilience scores as a result of an intervention.
Interestingly, two mindfulness-based studies found that the post-intervention mean resilience score was lower than the pre-intervention mean resilience score.
So does this validate my scepticism? Well, it certainly suggests there are no quick-fix solutions to the resilience issue. And no matter what any improvement guru might say, there are no off-the-shelf courses with which to ‘reprogramme’ doctors.
The bottom line is, while a career as a medical doctor may be incredibly rewarding, it can also be exceptionally demanding. It means being exposed to elevated levels of stress, high-pressure environments and feelings of uncertainty. Long working hours and sleep deprivation don’t help. And the increasingly regulated, administrative nature of the work is one of the reasons for the increasing levels of burnout being reported by medical staff.
What do you think? Am I being cynical about resilience and its alleged fixability?