Resilience in medicine

Resilience in medicine

Vijay Gopichandran

Resilience is the capacity of individuals to recover quickly from difficult situations. It is the measure of the ability of a person to pull themselves together after a fall and get up. Many patients are highly resilient. Some of them go through extreme hardships physically, psychologically and socially. Despite these hardships, they bounce back and operate optimally in their social spheres. Yesterday I saw a 70-year-old lady, a schoolteacher who came to me with complaints of extreme tiredness and fatigue. She also complained of a low-grade persistent feeling of fever that was troubling her for more than 4 months. As she walked into my clinic and sat in front of me, her positive energy and cheer instantly caught up to me. She was the personification of maternal care and love. She referred to me with words of endearment such as “Kanna”, “Raja”, Tamil words which are spoken to young boys by their mothers and other elder women, out of love. When our clinical encounter finished, and she left the room there was a feeling of warmth and kindness that was radiating all around. She is a classic example of how resilient, patients can be. Suffering and pain, physical, mental and social, have been the most constant companions in her life. She has undergone three abdominal surgeries for various painful illnesses involving her uterus. She has a spinal abnormality called scoliosis which is an abnormal sideward bending of her vertebral spine, because of which she suffers from chronic back pain and over and above that she worked as a school teacher till about 5 months back, standing, speaking and working for more than 10 hours a day. She has two daughters, the elder suffers from sequelae of childhood polio illness. The elder daughter is paralyzed from the hip downwards and is largely dependent on her for moving around. The second daughter, who married her college mate at the age of 19 years, was recently divorced and this was a matter of serious social pressure and concern for her. The past 50 years, since polio attack of her elderly daughter, this mother has lived a life of pain and suffering. But she typified resilience. 

Instead of withdrawing from society because of her physical and social pressures, this woman dived deeper into life and got more engaged. The mother in her most likely felt a deep sense of guilt for the polio of her daughter and the resultant disability. But instead of withdrawing, she gave of herself in the care of her daughter and in the care of thousands and thousands of children whom she taught in her class during her 40 years of teaching service. Sometimes, when people suffer from a lot of physical and mental pain, they just go about the movements without engagement. But this lady chose to overlook her suffering and engaged more deeply in life. Rather than becoming a rigid and self-flagellating person that some people turn into, this woman exhibited a great degree of love for herself and great flexibility. Having a physically dependent daughter precluded her from moving to different cities for her career development and promotions, but she compensated by being more engaged with her students in her hometown and being the exceptional teacher that she is. The flexibility in the face of difficult decisions helped her remain relevant. Instead of fragmenting herself into pieces – a piece, which was suffering from physical pain, a piece which was mentally traumatized by the worry and concern about her physically disabled daughter, a piece which was struggling to make meaning out of her career – she integrated herself into this complete mother-woman-teacher whose life was committed to all the roles in equal measure. She never feared change in her life. This was because the change was the only constant in her life, change from one pain to the other, one suffering to another. But she embraced all changes with wide open arms and courage in her heart. This is the kind of resilience that she exhibited.

But I am not sure if we as doctors are as resilient as some of our patients. Being a doctor is not a walk in the park. Especially working as a primary care provider in a resource-poor area can be highly distressing. Sometimes we know very well that a treatment will help a patient, but the patient may not be able to afford it, or worse still they may not be able to access it. Such circumstances push the physician into a state of helplessness and distress. These circumstances push them to question the very meaning of their work. Last week, I saw an elderly man in the clinic with a complaint of a sense of blockage and difficulty in passing urine. He has seen doctors in the tertiary care center about 50 km from his home. He was diagnosed to have an enlargement of the prostate, for which he needed to undergo a surgery. But this man was a lone elderly man with absolutely no financial or family support. He feared to undergo the surgery and believed that if he took to the hospital bed, that would be his end, as there was nobody to help and support him. I prescribed medicine which is known to reduce the level of blockage of the urinary pipes so that he would feel better with temporary relief of symptoms. But sadly, he was not able to access the medicines either, as the pharmacy which stocked the medicines were too far away from his village. I brought the tablets for him the next week from the city and gave it to him. But the one week he spent without the tablets proved to be highly painful and long for this poor old man. I felt frustrated at that time that I couldn’t do anything to help him immediately. Similarly, I have another lady who has oral lichen planus, a painful ulcerative condition of the mouth. None of the medical stores in her nearby town stocked the medicine that she needed. So, I had to get the medicine for her from the city. This again took a full week and her suffering during this week was very high. Another highly distressing situation for me has been when I have identified violent and abusive spousal relationships in case of some women, but have not been able to do much about it because of the strongly patriarchal social structure that would make this woman’s life more miserable out of the abusive relationships than inside it. Such frustrations and helplessness when it accumulates lead to burn out. Physicians working in these situations need strong support structures in place to stay resilient. 

It is traditionally taught that dissociation and detachment is a good way of staying resilient. If there is not much you can do in a medical situation for a patient, stay withdrawn, detach emotionally, is what the teaching says. Most of us do this subconsciously. I used to do this in my early career days when I was working in the ICU of a city hospital. I would completely dissociate myself from patients who were very critically ill and on the ventilator. I learned this dissociative behavior from my senior colleagues in the ICU, who were highly objective and clinical in their approach to such patients without much emotional investment. But now I strongly disagree with this idea. Withdrawal and detachment are not the answers for staying resilient, immersion and deep engagement are. We are all thinking, feeling human beings. Without emotional investment, we do not perform optimally at work. It is the emotional component that brings out the best effort from the physician. The strongest motivators for all humans are emotions. Anger, happiness, empathy, sadness, are all emotions that motive us and drive us to action. Withdrawal and detachment, therefore, impact our work negatively. On the other hand, immersion and deep engagement optimize our performance as a doctor. 

While being immersed and engaged, one should also be mindful of our emotions and feelings. All emotions have physical and visceral manifestations. I have noticed that my emotional distress manifests very early as mild neck discomfort. For some, it may be abdominal discomfort. When one identifies these early physical or visceral manifestations, one should immediately address the distress by adopting any of the coping mechanisms which give one the required resilience. This is the solution for staying resilient in trying circumstances and not emotional withdrawal. Moreover, immersion and deep engagement is the most realistic response for a doctor. This is because detachment removes one of the strongest motivations to perform optimally and it can be dangerous for the patient. 

The other commonly stated strategy for resilience is work-life balance. I believe that work-life balance is the most widely misunderstood construct. Human Resource Management texts define work-life balance as the state of equilibrium in which demands of personal life, professional life, and family life are equally balanced. There is a lack of opposition between work and other life roles. It is said that if the doctor can switch the “medical mind” off when she goes home, she achieves a better work-life balance. Several strategies are proposed to achieve this ‘switching off’ of the mind from work. The self-help guides which promote work-life balance ask their followers to ‘let go of perfectionism’. They say that perfection is not always possible and call the pursuit of perfectionism toxic and self-destructive. This cannot be any more distant from the truth, especially in medicine. This is because medicine is one of those specialties where there must be zero tolerance to errors. Having said that, it is impossible for individual physicians to be error-free and perfect, however, it must be the constant effort of every doctor to strive towards minimizing errors to the best extent possible. This error minimization cannot happen if the doctor ‘lets go of the attempt at perfection’. Every physician owes it to their patients to constantly strive to give their best while they are at work. This constant effort at minimizing errors does not come free of cost. There is always an opportunity cost for everything. Similarly, the constant effort to better oneself in the profession and doing the best for the patient often comes at the cost of compromises to personal time. It is not uncommon to see doctors work long hours and remain in hospitals for prolonged stretches of time caring for the patients and trying to make their lives better. Malcolm Gladwell in his book “Outliers” talks about the 10,000 hours rule, in which he says mastery of any art takes at least 10,000 hours of practice. I do not see these 10,000 hours as an absolute cut off point or a target that all medical doctors should strive to reach. I see it as an indicator of the long and hard hours of cognitive and psychomotor practice that is required. This roughly works to about 40 hours a week for roughly 5 years or 20 hours a week for about 10 years. Accounting for wastages of time during the typical working day, this cannot be accomplished if a doctor practices strict ‘switching off’ after the typical work week. 

On the contrary, I believe that resilience comes from immersion and deep engagement. A doctor achieves good resilience and avoids burn-out when she completely immerses herself in her work. This is because such a doctor learns to find islands of personal excellence, identity, purpose in life, pleasure and relaxation within the framework of her job. I am not prescribing that all doctors must not have a personal life, a family, or any other pursuits. I am proposing that consciously searching for the work-life balance in medicine is a futile attempt. Balance is a mirage; it is not true. Consciously looking for it will only worsen the stress of the life situations. Instead, a doctor should immerse herself without inhibitions. Understanding and accepting the unique nature of the profession and that it does not go hand in hand with a perfect work-life balance is the way to developing greater levels of resilience in medicine. I have found greater peace when I have accepted that my life and my work cannot conflict with each other. When I have stopped the conflict between them, by building pleasurable moments inside of my work, I have found more peace. Here are some important changes which I think all doctors and doctors-in-making must do to their lives to develop greater resilience:

• 1.      Taking short power breaks during work hours and engaging in short bouts of de-stressing activities – music, dance, gym, gaming, chatting – whatever it is. 
• 2.      Identifying the works that one is good at – some of us are good at procedures, some of us are good in documentation, some of us are good in communication – sharpening those skills and be the go-to person for that work. This makes us feel needed, important, respected and purposeful. 
• 3.      Being more forgiving of the self rather than being highly demanding. It is important to avoid errors. But errors happen. One must be self-forgiving, at the same time learning from mistakes and preventing them from happening again. 
• 4.      Being more mindful of one’s feelings, emotions – being emotionally intelligent. Identifying what one is feeling and ensuring that it is expressed appropriately. For example, if the patient that I am caring for dies, I should understand my own grief and must have an avenue to vent and cope with my grief. 
• 5.      Being more adaptable and accepting of changes is very important. In the face of obstacles, I must learn to innovate, adapt and change my strategies quickly.