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.
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