Resilience – from within or without?

 

I have been confused about resilience. To me, it always seemed very sensible to focus on it, this ability to ‘bounce back from tough times, or even triumph in the face of adversity’. It surely is part of the ‘hidden curriculum’, as Horne and Peters refer to it in their BMJ article, ‘Ensuring our future doctors are resilient’. Why not have seminars on it, why not encourage trainees to go on courses or listen to podcasts? It can even be measured [see table below, and the paper]; if so, improvements in it can be quantified. Why not instruct trainee doctors on how to marshal their inner resources, how to organise their lives, how to handle pressure, criticism and fear of failure? Many senior doctors who have pitched and swerved along their own professional journey will say – yes! I would have appreciated that!

From ‘Development of a new resilience scale’ by Kathryn Connor and Jonathan Davidson. Each component is scored 1-5, with the most resilient respondent having a score of 100. This score was designed primarily for psychiatry patients but has been used in studies for involving doctors.

 

Then I began to sense a backlash. Or an alternative philosophy. Clare Gerada writes frequently on the subject, spurred in large part by her involvement with the families of doctors who have committed suicide while under formal investigation. This tragic group is at the far end of a spectrum, and although their experience must force us to take heed, I am not sure the daily challenges met by trainees are in this league; or perhaps the risk of a catastrophic breakdown is routinely underestimated. There have been enough such tragedies for us all to be on our guard.

The alternative philosophy – my interpretation – is that resilience should not come entirely from within, but should grow through mutual support with our peers. In an excellent review ‘Doctors need to be supported, not trained in resilience’, Gerada and colleagues explore the foundations of resilience (organisational, individual and cultural factors) and are not impressed by the evidence that ‘teaching’ resilience is particularly effective. She concludes,

Although individual factors play a part in improving resilience and training can improve resilience, they do so in only a small way. Larger effects are achieved through creating posts, career structures, and team working to improve job satisfaction and continuity and through building in time to think and reflect for all staff and redressing the current bullying culture of shame and blame.

This transference of responsibility for resilience runs counter to, say, this presentation by a Leadership Fellow at Health Education England which appears to put the onus of resilience on the doctor. ‘We owe it to our patients’. Is it we, or is it them – the culture, the NHS, the Trust – who are the source of strength?

From a presentation by Dr Beatrice Downey, Leadership Fellow with HEE: ‘How resilient are doctors and can resilience skills be taught?’

The endpoint of this alternative philosophy is to dissociate the development of resilience from the particular qualities of the individual. Those on the extreme of the reaction against resilience would propose that culture and systems are directly implicated in cases where doctors lack resilience. In fact, resilience has become something of a dirty word [see tweet below]. Perhaps, in a perfect culture, it should not be needed at all.

A supportive culture that does not allow blame to be placed on individuals will ensure that no doctor will leave the hospital in a black swirl of self-doubt and assumed culpability. If a patient has been harmed or has died through medical error, the fragile human who was closest to the event, and who appears to be ‘implicated’, will of course feel fearful and guilty. Most would agree that our culture should ensure that before they leave, they should understand that there is always more to the narrative. The system allowed the mistake to happen; it was poorly designed. We will get through this with you. Don’t worry. The main thing is that you bounce back…

Yet, as someone who has both supported younger doctors who were involved in error (or complications) and experienced the sickening realisation that I have myself done harm, I know that however supportive the culture, individuals do blame themselves. They take the hit. This may be an inevitable consequence of medicine’s tradition: the therapeutic interaction is an intensely personal one. The patient must trust the doctor completely, and doctor must concentrate entirely on delivering the best of themselves – their knowledge, their effort, their instinct. The decision that arises from the moment reflect entirely on the doctor. If it is wrong, the doctor will naturally doubt themselves. Even if, on further investigation, the system was at fault for permitting that decision to occur (for example, an electronic prescribing system permits an insulin dose to be duplicated without raising an alert), the doctor will go through a period of hell. They will take the blame, even while their seniors seek to learn system-wide lessons. They will visualise the consequences – the unconscious patient, the terrified family. Then, if they are resilient, they will surface. They will be stronger and better, partly because they will have developed a heightened sense of caution when prescribing potentially dangerous drugs, and partly because they will have learnt that is not really possible to do medicine without occasionally causing harm. Understanding how to deal with that, while avoiding paralysis or endless self-recrimination, is part of resilience.

As a clinical and educational supervisor, I have to find a place on the line that runs between two cultural extremes. The ‘traditional’, blame-centred one in which trainees are expected to ‘go home and sort themselves out’, and the modern ideal that lifts all hints of personal accountability/responsibility (aka ‘blame’) from their shoulders. The reality, as ever, must lie somewhere in the middle. The older types who ‘suffered a 1 in 2 rota but learnt my trade’ and ‘got through the bad times’ must accept that younger colleagues will not thrive in the same model. Some will take the pain home, a very small proportion may develop unhealthy, dark thoughts. In the words of Dr Nisham Malek writing in Pulse, on the differences between Generation Y trainees and the old guard,

I can’t see the system meaningfully adapting in time. So, if our seniors care to bridge that gap, it can only start with looking within their own circles of influence: in opportunities to invest in meaningful relationships with trainees, in their ability to provide some stability as they’re buffeted around, and in their power to encourage and protect their sense of purpose.

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