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What we don’t talk about when we talk about professionalism: Resilience

Medical students now all have to have formal resilience training. But is resilience a trainable skill?

Katherine Ripullone and Kate Womersley

The General Medical Council views resilience as a critical part of becoming a “professional”.  All graduating medical students should have proved that they are resilient, and NHS job specifications expect it. They define resilience as “the capacity to recover quickly from difficulties.” It implies “toughness”, and an untiring effort to do more, to work faster, and to be better. The Medical Schools Council suggests screening for resilience in interviews, and now once admitted, medical students receive formal resilience training as part of the curriculum. The GMC’s “Professional Behaviour and Fitness to Practise” guidance underlines the importance of emotional resilience, which it defines as an “ability to adapt and be resourceful, mindful, and effective in complex, uncertain, or stressful situations.”

This sounds impressive, but is resilience a trainable skill? Confusingly, it is also presented as an intrinsic part of any good doctor’s personality. Can you detect resilience, let alone teach it, and does increasing the resilience of individual doctorsif indeed that’s possiblereally improve patient care?

We were among the first medical students to receive mandatory resilience training as part of our degree. Theories about resilience seeped into many aspects our education, particularly the GMC-mandated Situational Judgement Test (SJT), an exam which uses “realistic” clinical and professional scenarios to test candidates’ understanding of the “‘most appropriate” and “least appropriate” reactions to challenges on the wards. The exam’s ostensible purpose is to test a candidate’s ability to cope with complex medical and interpersonal situations when senior support isn’t readily available. However, many of the questions encourage juniors to take on additional, perhaps even unsafe, levels of responsibility. The expectation is that they stay overtime, agree to additional shifts, and make clinical decisions even if they feel uncertain if in the familiar position of being short-staffed. The SJT frames professionalism as a readiness to fill gaps in a leaking system, and lessen pressures which lie outside of individual doctors’ control.

This top-down emphasis on resilience comes at a time when many claim that today’s doctors are less resilient than previous generations. David Peters, director of the Westminster Centre for Resilience, and colleagues wrote an opinion piece in The BMJ warning about the “absence, illness, and attrition of expensively trained professionals.” In order to tackle “epidemic” levels of burnout among doctors, one solution has been to try to increase their resilience. “We believe that educating medical students and doctors to be resilient would be cost-effective”, Peters and colleagues argue, as they have a “higher prevalence of mental health issues than other student groups, and yet are less likely than their peers to seek help.”

Terence Stephenson, the past chair of the GMC, agrees. He supports emotional resilience training for doctors, an approach borrowed from the military: it has been part of the US Army’s “Comprehensive Soldier Fitness” (CSF) programme since 2008. Aside from the pressing question of whether medicine should be translating military principles into its practice, no robust studies support the efficacy of this type of training, nor its suitability for clinical care. The NHS and GMC are applying an unproven methodology from combat stress in Iraq and Afghanistan to doctors working in the UK.

In fact, resilience training expects that individuals merely adapt to system-wide challenges within healthcare, rather than address them. Compensating for a flawed system sounds more like compliance than resilience. Rationed resources, rota gaps, and overstretched teams are inevitabilities of care delivery: that’s just “how it is” in today’s NHS. Resilience rhetoric assumes that everyone experiences their working environment in the same way, regardless of sex, race, background, or personality type. But trainees’ own biographies and identities profoundly affect their responses when negotiating risk and uncertainty, as well as when party to distressing events and testing decisions.  

Resilience is most problematic when presented as a form of self-care. The GMC state that personal development and career success require “emotional regulation strategies, coping styles and…adopting helpful self-nourishing daily habits.” Such steps towards wellness might include yoga at work, regular exercise, portfolio reflections, and mindfulness training. As beneficial as these activities might be, Pooja Lakshmin, a psychiatrist in Washington D.C. (who writes about how the US healthcare has also fallen for the idea of resilience), recently explained how this “faux self-care” is misleadingly presented as a “panacea” to medical professionals. The reality is that there is a working limit which everyone “will always feel ashamed for reaching … because that is what our medical culture prescribes. That limit is not a weakness. Being overly-resilient, particularly when working with patients who need responsive caregivers, threatens empathic medical care.

Doctors do not need to be more resilient, Lakshmin argues: in fact, they have been “too resilient”. Selling resilience as a form of personal nourishment puts the responsibility for change firmly on the individual, while letting the system off the hook. Working conditions for doctors have become more demanding, and less secure. Resilience deflects accountability for doctors’ struggles away from understaffed, inadequately-funded and poorly-managed organisations, onto the people who work within them.

Focusing on individual resilience is the wrong way to address a critical problem: how do doctors cope in a profession that exacts a unique emotional, intellectual, and psychological pressure? If you were to ask trainees whether resilience training, or protected break times with reliable work schedules is more likely to improve their effectiveness and satisfaction at work, support for the latter approach would surely be resounding. Moreover, newly-implemented wellness weeks and lunchtime resilience seminars have a whiff of PR about them. There are valuable exceptions such as Schwartz rounds, but Clare Gerada in The BMJ rightly regrets that “structures within medicine where doctors can come together to train, work, play, and reflect together have been reduced or removed completely…The lack of those informal spaces threatens our ability to build the resilience we need to work.” Teams are looking less like robust collaborations, and more like collections of individuals each trying to be tougher.

The professionalism curriculum needs to be revised with a focus on resilient systems rather than resilient doctors. Workplaces would do better by defining resilience as a shared value rather than an individual asset. Otherwise, resilience risks becoming a single metric with which to deny the sensitivities and valuable differences that come up over the course of training. Medical students should be taught about their employment rights, the importance of handing over work when the day is done, mutual support for colleagues to take breaks, and raising concerns with seniors without intimidation. It is time for junior doctors to be empowered to build more resilient systems—to whistleblow, to advocate, and to speak out against wrong. It is the GMC’s responsibility to embolden this potential in the next generation.

 

Katherine Ripullone is an academic FY1 at the Norfolk and Norwich University Hospital

 

 

 

Kate Womersley is an academic FY1 doctor in Edinburgh

 

 

 

 

Competing interests: None declared