Last month two of my Foundation colleagues wrote an opinion piece on resilience training which brought a simmering topic to boil[1]. The article itself was an interesting take and there have been many of them recently, directly correlating with worsening working conditions within the NHS. Everywhere you look, medical media is saturated with the concept of resilience as the answer to poor morale among doctors. I don’t fault the writers; I think that they’re genuinely trying to help. However, talking about resilience is a short term solution and I’d like to move the frame of discussion away from it[2].
For the uninitiated, resilience is “the ability to adapt to changing circumstances, even when the circumstances are discouraging or disruptive.”[3] Ahead of graduation, my medical school ran special resilience classes to prepare for the working world where it was analogised as the quality of grass to bend and not break in a gale. An admirable quality, to be sure, but the solution to the present staffing crisis it is not.
To understand where the problem begins, I think it’s helpful to discuss the burgeoning Mindfulness Industry[4]. Mindfulness is the process of drawing one’s attention to the present moment. It has its roots in Zen Buddhist meditation and has gained currency recently in concert with resilience training to alleviate symptoms of depression and anxiety[5].
Where I use the term ‘Mindfulness Industry’, I refer to the strange development of this therapeutic discipline into an approach to conquering stress in the 21st century. Yet another pseudoscientific string to the bow of the self-help and life-coach markets, it seems. Placing aside the trouble of selecting Buddhist traditions and isolating them from the other traditions of non-materialism and compassionate ethics (which might cause trouble in corporate boardrooms), I’d like to examine the problem in using these as a blanket solution to work-related stress.
By resting the emphasis on cultivating resilience and mindfulness, we lay the responsibility of work-related stress at the feet of the individual. When we solely recommend resilience training, the injured party can infer that the fault lies with them. Having trouble with long hours and lack of support? You mustn’t be resilient enough; we can fix you. This approach doesn’t seem to recognise the external factors contributing to work-related stress. Instead, the impetus is on the individual to improve. While it may be championed with best intentions, the process is dehumanising; reducing the employee as a means to achieve a service and not a complex individual providing a service and an end in themselves.
At present the NHS is facing a staffing crisis with over 100,000 workforce shortages[6], with many doctors delaying entering further training or leaving the professional altogether[7][8]. Working in these circumstances is difficult. As one of these junior doctors looking to delay entering a training programme, I must first say that I do love my job and often enjoy working as a junior doctor. What I have found frustrating are the rota gaps, the lack of senior support and the view that I am often present as service provision as opposed to receiving training. At times it has been highly stressful and occasionally demeaning and I know I am not alone in feeling this way. I wholly sympathise with anyone who’d like to take a career break.
In these circumstances, it is not unreasonable for NHS England, the GMC or collegiate services to attempt to turn the tide. They might say, provide reasons for junior doctors to stay instead of pushing unpopular changes to the shape of training or endorsing a contract with a pay cut in real terms. They might cultivate a working environment which is more pleasant instead of asking the affected juniors to look within and change.
I do not take umbrage with resilience or mindfulness in of themselves. They seem to be helpful to a growing number of people in crisis. What does cause me concern is the tunnel-vision approach which regards this inner development as the only solution. Resilience should be a tool for inevitable unpleasant features of working as a junior doctor; failed resuscitation efforts or breaking bad news. It is inappropriate to give it as advice to ‘toughen up’ in the face of preventable stressors such as rejected leave requests, workplace bullying and rota gaps.

References
1. Ripullone Katherine, Womersley Kate. Is resilience a trainable skill? BMJ 2019; 365 :l2162
2. Huntington G R. Resilience training is a slap in the face BMJ 2019; 365 :l4176
3. Collard B, Epperheimer JW, Saign D. Career resilience in a changing workplace. (ED 396 191). ERIC Clearinghouse on Adult, Career, and Vocational Education, 1996
4. Purser Ronald. McMindfulness; How Mindfulness Became the New Capitalist Spirituality. Repeater Books 2019.
5. Johnson Jill R, Emmons Henry C, Rivard Rachael L, Griffin Kristen H, Duske Jeffrey A. Resilience Training: A Pilot Study of a Mindfulness-Based Program with Depressed Healthcare Professionals. Explore 2015 11:6 433-444.
6. Health Foundation, King’s Fund, Nuffield Trust. The health care workforce in England: make or break? Nov 2018.
7. Programme. UF. Foundation Programme. Career destination report. 2017.
8. Council GM. The state of medical education and practice in the UK. 2018