Practicing medicine is dangerous!
The modern-day boiler room continues to exist in the Operating Suite. The amount of resilience and fortitude it takes to survive the training alone could compare only to other high stress and high stakes jobs like bomb disposal technicians. There is no wonder that physicians command the highest suicide rate second only to Marine Engineers. Yet despite this little has changed in medicine to help alleviate this burden and young self-sacrificing medical students will continue to choose a profession that may literally kill them.
Some people are extraordinary
The buzz word for physician burnout in the medical journals and c-suites continues to revolve around Resilience. Not fully understanding the concept and recently overcoming the throes of burnout, I decided to investigate for myself what this concept means and how it applies to my situation.
What is Resilience? According to Friborg1:
For centuries, writers have been inspired by the extra-ordinary capacity some people show in combating adversity or misery. In psychology, however, the study of unexpected positive outcomes, today referred to as resilience.
The historical background of resilience:
Since 1995 numerous researchers have sought out a way to define, organize and ultimately measure the elements of resilience for two reasons 1:
- “It may provide evidence about which factors are most central for regaining and maintaining mental health for different patients.”
- “It may help in the selection of personnel who will manage tougher job demands.”
Ultimately the researcher’s search for the elements or traits of a person which would enable them to survive “extraordinary” circumstances. Instead of looking at the problem, the focus centers on the individual and mechanistically structures a person who can withstand stress, a super being. Therefore if they fail the person was not good enough to handle the pressure.
Hopefully, this leads to flashbacks in your own career or training. “Calling me is a sign of weakness” as an example. We self-select in medicine in general and surgery in particular to find the person willing to take abuse, pressure, sleep deprivation and very long hours to maintain the façade of the profession. Some call it “training” others may call it educational Brainwashing, look up Patty Hurst, one of the most famos examples in this country.
What are the pillars of resilience?
They are known as the Big 5 in psychology which includes:
- Extroversion
- Openness
- Neuroticism
- Conscientiousness
- Agreeableness
The original list included 16 different factors but over time researchers discovered these five were the most important and they seem to be universal across many customs and cultures. The test subject gets measured on each of the five traits and then assigned a score. This score then can potentially predict which person will crack under pressure. According to Friborg each of the big 5 carry different weight and can be more predictive than other traits.
Openness
This trait reflects a person’s ability to have tendencies toward fantasy, aesthetics, feels, ideas and values which are usually clustered together. “Openness involves six facets, or dimensions, including active imagination (fantasy), aesthetic sensitivity, attentiveness to inner feelings, preference for variety, and intellectual curiosity2.” On a very basic level some people are considered to be either open or closed minded within a spectrum.
Extroversion
This trait consists of the following factors sociability, social impact, leadership, competitiveness and social boldness. When combined with social competence, it creates a network effect where the individual by extension would usually have a stronger family cohesion and supportive friendships which could help in times of crisis in both magnitude and number.
Neuroticism
All the traits are positive when present but the opposite is true when neuroticism is present. It can be thought of as not having emotional stability and instead exhibits degrees of depression, anxiety and impulsiveness. A person with a high degree of neuroticism usually is self conscious and therefore vulnerable to outside influences. Usually negative thinking dominates beliefs of self and of the future in general. As a result it is possible to have difficulty planning for the future. This was not my favorite subject to research, It got me nervous!
Conscientiousness
Claimed to be the most important trait since it gives the most protection from stress and confers the ability to recover more rapidly after an insult. Not impulsive the conscientious person prefers planning using routine and habits to guide achievement. As a result they typically have the strongest work ethic and get the most education. One of my favorite sayings, “if you are on time, you are late,” reflects the singular drive of the conscientious trait, punctuality.
Agreeableness
Usually considered a weakness by the strong-willed, bootstrapping doctor, this trait really reflects what we need most as healers and mentors which strongly corresponds with empathy. Not a pushover the agreeable person has the ability to harness a sense of closeness toward relationships with peers, family and patients. As a result are capable of creating more trust and cooperation within these relationships. Not a bad idea if we want to create more social credit with the people in our lives.
After reviewing these traits and taking time digest them, a clearer picture began to emerge in my own life. I also took the Resilience for adult test and to my surprise I didn’t have a perfect score or even close! Am I a resilient person or not? Can I become more resilient by aligning myself with the Big 5? Curiously cognitive ability according to the data actually places a person more at risk than if they were of average ability. Then there is social intelligence which is defined as the ability to:
- Process social information
- Social Awareness
- Social skills (belief in one’s abilities)
If I can’t change who I am perhaps I can gain some skills to soften the blow. Social intelligence combined with agreeableness can lead to overall greater social competence with resultant greater social resources. In time of stress people with a support network will not only get direct support in number but also in magnitude. The more we plant seeds in the spring the greater the harvest in the fall. Networking in this regard is lifesaving in times of crisis and most people like myself will always go at it alone. I have since then changed course and make every effort to bring agreeableness into my life as best I can.
Am I resilient? I am not sure but do physicians need extraordinary abilities to survive the operating room environment? Until the fundamental question of why the culture persists, the answer is… Get your superman/superwoman outfit on, and serve me a double dose of cortisol.
DOAT
1International Journal of Methods in Psychiatric Research, 2005, Volume 14, Number 1, pages 29–42
Great post DOAT. Out of the 5 pillars, I believe agreeableness and extroversion lead to a more robust social network, and as you astutely point out, more social support resources in number and magnitude. Those pillars provide a safety net of friendship. The other three traits, openness, conscientiousness, and neuroticism point toward the individual’s ability to “let things slide,” “roll with it,” or “be open to more than one answer,” thus the safety net is within the individual. I wonder if, for those introverts out there, developing the latter three might be an easier start in building resilience. Looking forward to your next post.
Excellent points! I like your overview and ability to tease out the general differences between external and internal safety nets. I actually have been contemplating the utility of directed personality tests looking for traits that place a place a person at risk versus another. My favorite example is the Mars social experiments where a group of individuals were exposed to the conditions you would experience in an extreme environment. Despite choosing for applicants with a similar background and training the human factor always resulted in one or two of the astronauts cracking under pressure. Although the medical work environment is the major culprit in creating an extreme working condition which presses the best and brightest into submission. Short of changing the culture and establishment our only hope is fortify ourselves using whatever tools we can find. I personally have used a career coach and this single act has made all the difference.
As Casey Kasem says: Keep your feet on the ground and keep reaching for the stars! DOAT
Thanks for writing this DOAT. With my burnout this year, yes, I wondered if My resilience (of lack thereof) was a factor in it. I can see the extroversion, openness, and agreeableness being key traits in resilient people as they allow for conflict avoidance and resolution, thereby creating friends and outlets of stress relief. I was a bit surprised by neuroticism being on that list.
Resilience certainly helps soften the blows. We need to be aware that the blows themselves (our workload, and nature of the job) are the other half of the equation and also need to be dealt with to mitigate burnout.
Neuroticism is a very useful personality trait and often gets the ugly step-sister treatment. Since we are all a blend of the big 5 with a predominance of one over the other, the three that you mentioned reduce or prevent burnout whereas neuroticism does not. However, having a healthy level of neuroticism can prevent us from making mistakes in medicine especially when lives are at stake. The problem arises when we may have too much of it or have a predominately neurotic personality. These people burnout twice as fast as everyone else since they spend their time double-checking everything. You know the type! The solution then will be to seek help for both the underlying personality disorder and literal help with some else doing the double checking for you. I highly recommend the book, “The happiness hypothesis,” where Jonathan Haidt explains that our minds are no different than any organ system and we are either blessed or cursed genetically. Since every society, doctors included, have the same distribution of mental illness or personality disorders it is very important to screen and help those who would benefit from treatment. The book is a self-scan to see if you may be a candidate for getting a face-lift for your brain with meditation, CBT or medication. The literature is clear when it comes to physicians, they never seek help until it is too late and in many cases, if they seek the help they can be sanctioned by their medical boards. It is a very delicate situation. According to recent studies, as much as 70% of physicians have symptoms of burnout which to me indicates that it is more of a systemic problem but how certain physicians handle the stress could mean the difference between success or disaster. In my opinion and what has worked for me is to not ignore signs of burnout and have a plan for dealing with it. So far I have tried daily meditation with some success and backing off my clinical work made all the difference in the world. Many doctors do not have the latter option due to the nature of their work or specialty. They need to reach out to their partner and/or employers to tell them what they need, like less call etc. IF they don’t reciprocate then it is time to do some soul searching and perhaps find a venue that does give you what you need. Lastly, there is nothing wrong in seeking professional help and talking it over with a professional or undergo CBT. Plain and simple, it works and many of our peers who we see suffering should really seek help.
Wow that was long!
Stay Strong and Keep Fighting!
Doat