This week there has been a bit of a debate going on in our department over appropriate blood pressure targets for the elderly. This debate started in light of the eighth Joint National Committee (JNC 8) guidelines, and has revolved mainly around balancing outcomes with adverse effects, NNTs, and patient engagement in medical decisions. As I’ve observed (and participated just a bit in) this debate, in the back of my mind I keep thinking of my patients who do not fit the expectations of JNC 8—or any other guidelines for that matter.
Reading JNC 8 or the 2013 American College of Cardiology/ American Heart Association guidelines—both of which I think are reasonably evidence based—one gets the clear message that those found to be at risk, and who do not follow the recommended treatments, will have all sorts of horrible things happen to them: stroke, heart attack, and early death. Writ large, this ties into growing concerns about the global “epidemic” of non-communicable chronic diseases.
I’ve certainly had my share of patients who have died untimely deaths due to chronic diseases, yet I’ve also had those who seem to nearly completely ignore my advice . . . and yet they still keep on going and going and going. Despite uncontrolled blood pressure, high cholesterol, regular smoking, and lack of activity—they keep on going!
I’ve joked more than once that such folks owe their longevity to their obstreperousness or cantankerousness, and often that seems to ring true. Not always, but at least sometimes it’s the “characters” that just keep on going.
“Resilience” has been getting more and more press in the medical and psychological literature, and is defined as: “The process of negotiating, managing, and adapting to significant sources of stress or trauma . . . ‘bouncing back’ in the face of adversity.” 
This is postulated to be a more “asset based” approach to understanding mental health, as opposed to “’deficit’ models of illness and psychopathology.” So far so good, and I get the concept of “bouncing back,” but it turns out that we still do not know clearly how to operationalize, measure, or define it in practical terms . What’s more, scales seeking to measure resilience all measure reactions, not proactivity.
“Obstreperousness,” by contrast, seems more “positive”—at least in the sense of being a description of one’s initiated activity, not a description of reactivity, and it turns out we know even less about it. The only research I could find on “obstreperousness” is nearly 20 years old, and has to do with “aggressive, assaultive, motor” behavior by demented patients .
“Grit” (the attitudinal kind, not the particulate kind) has been defined as “perseverance and passion for long term goals” , and has been found to be predictive of success among surgical residents  and rural family doctors . So at least we know that docs with “grit” seem to have “stick-to-it-ive-ness.”
How do we relate this to our patients? The concepts of motivational interviewing are now being applied in general medicine in an effort to engage patients in understanding what makes themselves tick, and to encourage patients to move in a more healthy direction. Yet this is still focused on engaging patients’ intrinsic motivations, not with helping them find motivation, passion, or perseverance.
Admittedly, at this point the discussion is becoming more about identity, spirituality, and direction in life—but I think all these do have a bearing on who our patients are, where they go, and what they do with their lives.
It’s one thing to measure resilience, obstreperousness, or grit, and an entirely different thing to encourage or promote it. And none of this means I’m going to forgo recommending evidence based treatments for chronic or acute conditions. I’ll still recommend appropriate medications where the evidence indicates that they can improve morbidity and mortality, and I’ll still encourage my patients to eat their fruits and veggies and get plenty of exercise.
But I think, too, it’s time for us to pay a bit more attention to those patients who are survivors—those who keep going despite ignoring our well meant, evidence based advice. How do they do it? Passion? Perseverance?
Perhaps those we find obstreperous or overly aggressive, may have the resilience and grit to keep on going.
 Windle G, Bennett KM, Noyes J. A methodological review of resilience measurement scales. Health Qual Life Outcomes. 2011 Feb 4;9:8. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042897/)
 Drachman DA, Swearer JM, O’Donnell BF, Mitchell AL, Maloon A. The Caretaker Obstreperous-Behavior Rating Assessment (COBRA) Scale. J Am Geriatr Soc. 1992 May;40(5):463-70. (http://www.ncbi.nlm.nih.gov/pubmed/1634698)
 Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: perseverance and passion for long-term goals. J Pers Soc Psychol. 2007 Jun;92(6):1087-101. (http://psycnet.apa.org/journals/psp/92/6/1087/)
 Burkhart RA, Tholey RM, Guinto D, Yeo CJ, Chojnacki KA. Grit: a marker of residents at risk for attrition? Surgery. 2014 Jun;155(6):1014-22. (http://www.ncbi.nlm.nih.gov/pubmed/24856121)
 (Reed AJ, Schmitz D, Baker E, Nukui A, Epperly T. Association of “grit” and satisfaction in rural and nonrural doctors. J Am Board Fam Med. 2012 Nov-Dec;25(6):832-9. (http://www.jabfm.org/content/25/6/832.long)
William E Cayley Jr practises at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.
Competing interests: “I declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare beyond a passion for clear and critical thinking.”