{"id":44230,"date":"2019-03-14T16:29:42","date_gmt":"2019-03-14T15:29:42","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=44230"},"modified":"2019-12-17T11:15:36","modified_gmt":"2019-12-17T10:15:36","slug":"what-we-dont-talk-about-when-we-talk-about-professionalism-resilience","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/03\/14\/what-we-dont-talk-about-when-we-talk-about-professionalism-resilience\/","title":{"rendered":"What we don\u2019t talk about when we talk about professionalism: Resilience"},"content":{"rendered":"

Medical students now all have to have formal resilience training. But is resilience a trainable skill?<\/p>\n

<\/p>\n

Katherine Ripullone and Kate Womersley<\/strong><\/p>\n

The General Medical Council views resilience as a critical part of becoming a \u201cprofessional\u201d. <\/span>\u00a0<\/span>All graduating medical students should have proved that they are resilient, and NHS job specifications expect it. They define resilience as <\/span>\u201cthe capacity to recover quickly from difficulties.\u201d It implies \u201ctoughness\u201d,<\/a> and an <\/span>untiring effort to do more, to work faster, and to be better.<\/span> The Medical Schools Council suggests<\/a> screening for resilience in interviews,<\/span> and now once admitted, medical students receive formal resilience training<\/a> as part of the curriculum.<\/span> The GMC\u2019s “Professional Behaviour and Fitness to Practise” guidance underlines the importance of emotional resilience, which it defines as an \u201cability to adapt and be resourceful, mindful, and effective in complex, uncertain, or stressful situations<\/a>.\u201d<\/span><\/p>\n

This sounds impressive, but is resilience a trainable skill? Confusingly, it is also presented as an intrinsic part of any good doctor\u2019s personality. Can you detect resilience, let alone teach it, and does increasing the resilience of individual doctors<\/span>\u2014<\/span>if indeed that\u2019s possible<\/span>\u2014<\/span>really improve patient care?<\/span><\/p>\n

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 <\/span>Situational Judgement Test<\/span><\/a> (SJT), an exam which uses \u201crealistic\u201d clinical and professional scenarios to test candidates\u2019 understanding of the \u201c\u2018most appropriate\u201d and \u201cleast appropriate\u201d reactions to challenges on the wards. The exam\u2019s ostensible purpose is to test a candidate\u2019s ability to cope with complex medical and interpersonal situations when senior support isn\u2019t 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<\/a> as a readiness to fill gaps in a leaking system, and lessen pressures which lie outside of individual doctors\u2019 control.<\/span><\/p>\n

This top-down emphasis on resilience comes at a time when many claim that today\u2019s doctors are less resilient than previous generations. <\/span>David Peters, director of the Westminster Centre for Resilience, and colleagues wrote an opinion piece in <\/a><\/span>The BMJ<\/span><\/i> warning about the \u201cabsence, illness, and attrition of expensively trained professionals.\u201d<\/span> In order to tackle<\/a> \u201cepidemic\u201d levels of burnout among doctors, one solution has been to try to increase their resilience<\/a>.<\/span> \u201cWe believe that educating medical students and doctors to be resilient would be cost-effective\u201d, Peters and colleagues argue, as they have a \u201chigher prevalence of mental health issues than other student groups, and yet are less likely than their peers to seek help<\/a>.\u201d<\/span><\/p>\n

Terence Stephenson, <\/span>the past\u00a0<\/span>chair<\/span><\/a> 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 \u201cComprehensive Soldier Fitness\u201d (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. <\/span><\/p>\n

In fact, resilience training<\/span> expects that individuals merely adapt to system-wide challenges within healthcare, rather than address them. <\/span>Compensating for a flawed system sounds more like compliance than resilience. <\/span>Rationed resources, rota gaps, and overstretched teams are inevitabilities of care delivery: that\u2019s just \u201chow it is\u201d in today\u2019s NHS.<\/span> Resilience rhetoric assumes that <\/span>everyone experiences their working environment in the same way, regardless of sex, race, background, or personality type. But trainees\u2019 <\/span>own biographies and identities profoundly affect their responses when negotiating risk and uncertainty, as well as when party to distressing events and testing decisions. \u00a0<\/span><\/p>\n

Resilience is most problematic when presented as a form of self-care. The GMC state that personal development and career success require<\/span> \u201cemotional regulation strategies, coping styles and…adopting helpful self-nourishing daily habits.\u201d Such steps towards wellness might include yoga at work, regular exercise, portfolio reflections, and mindfulness training<\/a>.<\/span> As beneficial as these activities might be, Pooja Lakshmin, a<\/span> psychiatrist in Washington D.C. (who writes about how the US healthcare has also fallen for the idea of resilience), recently explained how this \u201cfaux self-care\u201d is misleadingly presented as a \u201cpanacea\u201d to medical professionals. The reality is that there is a working limit which everyone \u201cwill always feel ashamed for reaching \u2026 because that is what our medical culture prescribes.<\/a>\u201d<\/span> That limit is not a weakness. Being overly-resilient, particularly when working with patients who need responsive caregivers, threatens empathic medical care.<\/span><\/p>\n

Doctors do not need to be more resilient, Lakshmin argues: in fact, they have been \u201ctoo resilient\u201d.<\/a><\/span> Selling resilience as a form of personal nourishment puts the responsibility for change firmly on the individual, while letting the system off the hook. <\/span>Working conditions for doctors have become more demanding, and less secure. <\/span>Resilience <\/span>deflects accountability for doctors\u2019 struggles away from understaffed, inadequately-funded and poorly-managed organisations, onto the people who work within them.<\/span><\/p>\n

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 <\/a><\/span>The BMJ<\/span><\/i> rightly regrets that \u201cstructures 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.\u201d<\/span> Teams are looking less like robust collaborations, and more like collections of individuals each trying to be tougher.<\/span><\/p>\n

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\u2014to whistleblow, to advocate, and to speak out against wrong. It is the GMC\u2019s responsibility to embolden this potential in the next generation.<\/span><\/p>\n

 <\/p>\n

\"\"Katherine Ripullone<\/strong> is an academic FY1 at the Norfolk and Norwich University Hospital<\/em><\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

\"\"Kate Womersley<\/strong> is an academic FY1 doctor in Edinburgh<\/em><\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

Competing interests<\/strong>: None declared<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Medical students now all have to have formal resilience training. But is resilience a trainable skill? […]<\/p>\n

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