Image courtesy: Ana Hategan

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.”
Rainer Maria Rilke

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:

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.

Skill building exercise

1. Where does your time go?

  • 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?
2. What would your ideal day look like?
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:

Other factors associated with greater wellbeing and less burnout are:

Skill building exercise

Test your knowledge

Greater mental wellbeing among residents is associated with:

  1. Higher in-training examination scores
  2. Greater empathy
  3. Lower subjective quality of life
  4. Increased alcohol use

Find out...
Answer: b
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.

Skill building exercise

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:

  1. Physical health
  2. Emotional health
  3. Professional satisfaction
  4. Spiritual/Social connectedness

A. Physical health

Skill building exercise

Skill building exercise

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

Skill building exercise

Seated meditation

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.

Skill building exercise

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).

C. Professional satisfaction

Skill building exercise

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? Learn more...
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


Online resources