Image courtesy: Ana Hategan
“Do not assume that he who seeks to comfort you now, lives untroubled among the simple and quiet words that sometimes do you good. His life may also have much sadness and difficulty that remains far beyond yours. Were it otherwise, he would never have been able to find these words.”
In the section Know Yourself, we discussed the definition of resilience, its components, why it is important, and challenges in residency training that impact trainees’ ability to be resilient. The purpose of the following module is to empower you with tools to build your resiliency muscles with practical methods and exercises.
Like any tool or skill, resilience should be honed and practiced on a regular basis. A proactive approach to fostering resilience might include frequent reflection and discussion, a holistic approach to self-care, and a positive mindset. We are taught a great deal about anatomy, pathophysiology, and the treatment of disease. Yet, we spend little time learning how to think about and manage stress, acknowledge suffering, discuss death, and cultivate “work-life balance” while marching on the tightrope of medical training.
Did you know?
Between 2011 and 2014, satisfaction with work-life balance declined (48.5% vs. 40.9%, p < 0.001) and burnout increased in physicians, whereas there were minimal changes in these observed measures in other working U.S. adults, demonstrating a disparity in wellbeing between these two working populations (Shanafelt et al, 2015).
There is an adage about the three stages of life and how the three elements of time, money, and energy are commonly distributed:
- In our teenage years, we have all the time and energy, but no money.
- In adulthood, we have money and energy but no time.
- In old age, we have all the money and time, but no energy.
As health professionals, it often feels like there is a dearth of all three elements (time, money, energy), which can tax our emotional and physical wellbeing.
1. Where does your time go?
2. What would your ideal day look like?
- Reflect on what your time sinks in a day are.
A "time sink" is an unplanned activity that does not add value/satisfaction/happiness to your day or ends up making you feel guilty later on. Time sinks can also be extra time spent on a planned activity because of multi-tasking or avoidable distractions.
- Go a step further and consider how you were feeling during the time sink activity?
For example, if you spent time texting a friend or on social media when you were supposed to be making phone calls or writing orders, what feelings might have led to that behaviour?
What could you do differently next time you find yourself in a time sink?
For example, if you find yourself taking extra time to write notes because your workstation is in a place with other clinicians or a busy patient unit, what could you do to be more efficient with your time?
Take five minutes to brainstorm what an ideal work day would look like as well as an ideal day off. Try and be as specific as possible. Topics to consider might include how you would start your day, what would you eat, how would you spend your free time, etc.
A systematic review by Raj (2016) reported the following factors that correlated with wellbeing measures:
- autonomy and a sense of control;
- competence (pursuit and achievement of goals, a sense of increasing mastery);
- social relatedness (positive feedback and positive colleague relationships).
Other factors associated with greater wellbeing and less burnout are:
- amount of sleep;
- physical activity;
- time in nature and away from work;
- being in a relationship;
- perceived social support (family, friends, support groups for physicians).
Test your knowledge
Greater mental wellbeing among residents is associated with:
- Higher in-training examination scores
- Greater empathy
- Lower subjective quality of life
- Increased alcohol use
Provider wellbeing has a direct effect on patient care, with patients feeling more cared for and clinicians feeling more present and connected with their work.
Do you want to explore how burned out you might be? Take a free anonymous online survey made by the Mayo Clinic that measures burnout.
Did you know?
A systematic review of 46 studies demonstrated an association between poor wellbeing and moderate to high levels of burnout being associated with poor patient safety outcomes (e.g., medical errors) but was not able to determine causality given the lack of prospective studies (Hall et al, 2016).
Methods to improve resilience
Over the past few decades, a paradigm shift has been steadily occurring within our model of health towards an approach focusing on factors that support human health and wellbeing (salutogenesis) instead of focusing heavily on factors that cause disease (pathogenesis). Similarly, when it comes to the health of our clinicians, we need to foster wellbeing and not just prevent burnout. Based on the literature, we can organize efforts to maximize wellbeing and improve resilience into the following domains:
- Physical health
- Emotional health
- Professional satisfaction
- Spiritual/Social connectedness
A. Physical health
- Sleep is at the most basic level of Maslow’s Hierarchy of Needs, which suggests it is a fundamental prerequiste for wellbeing:
- Start your day with:
- 10-20 minutes of movement: cardio, yoga, stretches, calisthenics, etc.
- Cross-fit, high-intensity interval training, yoga, mixed martial arts, spin-classes, and trail-running are just a few examples of group classes that might be offered in your community.
- Take advantage of your health benefits (e.g., massage, acupuncture).
- Use your body to relax the mind:
- Learn about self-relaxation techniques such as autogenic training (technique that uses imagery and concentration on bodily perceptions to improve relaxation) and progressive muscle relaxation (technique based on awareness and modulation of muscle tension).
- Maintain healthy dietary practices:
- Sufficient hydration, adequate vitamin D, limit or avoid excess simple sugars, refined starches, processed foods, caffeine and alcohol.
Can self-relaxation techniques help lower depression and anxiety in health professional students? Find out...
A European initiative offered a medical student level, two-term elective course called RELACS (recreation and success in learning through applied concentrative self-relaxation) incorporating elements of autogenic training and progressive muscle relaxation with the goal of reducing stress and eventual burnout symptoms in this population (Wild et al, 2014). The basis for the study is the internationally-recognized experience of those in the medical field; as one progresses through medical education, training and career, burnout risk increases, which highlights the urgency for early development of healthy, effective skills to manage stress to stave off long term consequences. Medical students in the RELACS course demonstrated a reduction in average depression and two types of anxiety: situational and trait. The study claims "it proved possible to counteract clinical and subclinical burnout" through learned relaxation techniques (Wild et al, 2014).
B. Emotional health
- Mindfulness meditation
- Mindfulness is often defined as the practice of paying deliberate attention to the present moment, with curiosity and without judgement, while accepting any thought, sensation, or emotion that arises. You can find guided meditations on YouTube or mobile apps like
Even 10 minutes per day of daily practice, especially in the morning, can help centre and prepare you for the day ahead.
Sit in a comfortable and dignified position with your feet on the ground and your hands on your lap. Start by becoming aware of the flow of your breath as it moves into and out of your body. Notice the experience in its entirety from start to finish. As thoughts arise, watch them float by like a leaf on a river. Practice letting go of the thoughts using your breath as an anchor to ground you.
Check out this link to practice a mindfulness exercise and journal your reflections upon completion. You may want to comment on such things as:
- Was the exercise easy or hard for you?
- Did you notice your mind wandering?
- What strategies did you use to bring you back to the present?
- Describe any sensations you felt in your body.
Did you know?
Meditative interventions can improve physical and emotional markers of wellbeing. A systematic review and meta-analysis of 27 studies on meditative interventions (mindfulness based stress reduction, mantra meditation, etc.) for health professionals found significant improvement in participants’ levels of emotional exhaustion, personal accomplishment, self-efficacy, and life satisfaction in controlled trials. Pre-post studies suggested improvements in stress levels as well (Dharmawardene et al, 2016).
- Peer process group
Start a process group (i.e., a peer group that meets regularly as a part of didactics or lunch time to discuss certain clinical experiences) to normalize the experience.
- Themes to consider: caring for dying patients, surprising clinical encounters, mistakes, blame, forgiveness, work-life balance and family time, other challenge or unexpected clinical outcomes.
Try an interdisciplinary approach by reaching out to other clinicians besides physicians who you work with (e.g., nurses, occupational/physical/speech therapists, technicians, social workers).
- Personal therapy
- A salutogenic (wellbeing promoting) approach that focuses on prevention instead of waiting to see a therapist during crisis only.
- Third-party, confidential EAP (employee assistance program) through the human resources department or student-resident counselling services.
- Reflective writing
- Keep a journal to reflect on and process your thoughts, feelings, ethical dilemmas, or “first” experiences.
- Voice memos, written pieces, sketches and drawings, paintings, or anything that helps you work through memorable or significant moments you experience on a daily basis can be helpful to find, rediscover, or rejuvenate meaning in your work.
C. Professional satisfaction
- A common complaint in residency is the perceived lack of control. Much of your schedule is decided for you within your contract or collective agreement; however, there are often opportunities to make requests, especially if you have a resident union. Be assertive and ask for things you would like:
- Specific holidays
- Mentors or supervisors
- Call dates
- Parental leave
- Ask clarification questions and do not be afraid to decline a demand that does not fit or seems unreasonable:
- Follow up with preceptors or attendings to review your evaluations.
- Aim to come from a place of self-improvement instead of defensiveness.
- Shape your training experience:
- Be active in residency steering committees to help shape your clinical rotations and didactics.
- Join quality improvement, ethics, pharmacy, or other hospital and leadership committees.
- Take advantage of teaching opportunities:
- Share your wisdom and experience with other students around you (e.g., peers, medical, nursing, ancillary staff).
- Treat all colleagues with utmost respect.
- Attend didactics or seminars on topics that interest you in other fields of medicine.
- Lead and/or participate in extracurricular and community-based workshops.
- Combat “imposter syndrome”: a common phenomenon in trainees and early career professionals of various fields, which involves feelings of being less than competent or doubting one’s knowledge and abilities, despite appropriate and adequate training.
How is support from fellow residents and faculty different than having a professional coach? Name three ways. Would the coach need to be a physician? Why or why not?
Coaching is a well-organized approach which aims to optimize one's professional strengths (Gazelle et al, 2015). Coaching's likely utility and application to tackle burnout in the physician is extrapolated from the field of positive psychology. Coaching incorporates the goals of identifying and addressing cognitive biases, exploring destructive patterns, which may be self-sabotaging, and developing effective means by which to combine strengths, needs, and objectives in professional life with those in one's personal life. Physician coaching is a budding field, with much research yet to be done. However, a promising stage has been set looking at how coaching can be successful in other professional fields.
Structured collegial support is yet another technique to combat burnout and build resiliency.
D. Spiritual/Social connectedness
- Practice spirituality however you define it:
- Visit a place of worship
- Make time to be in nature
- Go to art and cultural festivals
- Sangha meditation groups (community mindfulness meditation practice, often held in the Buddhist tradition, called a “Sangha”); however, it is usually non-denominational in its approach so as to evoke participation from a wider audience
- Make friends outside of the medical field:
- Join recreational sports leagues
- Take advantage of free classes (e.g., art, dance, cooking) at your local rec center
- Volunteer at your local museum, library, arboretum, Boys and Girls Club, Meals on Wheels
- Meetup groups
- Find ways to become more politically active.
- Dharmawardene M, Givens J, Wachholtz A, Makowski S, Tjia J. A systematic review and meta-analysis of meditative interventions for informal caregivers and health professionals. BMJ Support Palliat Care. 2016;6(2):160-9.
- Gazelle G, Liebschutz J, Riess H. Physician burnout: coaching a way out. J Gen Intern Med. 2015;(4):508-13.
- Hall LH, Johnson J, Watt I, Tsipa, A, O’Connor DB. Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PloS One. 2016;11(7):e0159015.
- Raj KS. Well-Being in Residency: A Systematic Review. Journal of Graduate Medical Education. 2016;8(5):674-84.
- Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600–13.
- Wild K, Scholz M, Rophol A, et al. Strategies against burnout and anxiety in medical education - implementation and evaluation of a new course on relaxation techniques (RELACS) for medical students. PLOS ONE. 2014;9(12):e114967.