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Lauren Forrest MD
Image courtesy: Ana Hategan
An individual’s wellbeing can be thought of as a dynamic state that is constantly being impacted by inputs (both positive and negative) that interact with an individual’s personality and temperament to lead to outcomes of resilience or burnout (Dunn et al, 2008). Positive inputs include support, positive coping strategies, mentorship, and intellectual stimulation (Dunn et al, 2008). Negative inputs include stress, internal conflict, and high demands on both time and energy that is required in the medical profession (Dunn et al, 2008). These factors interact with an individual to produce resilience or burnout in an individual (Dunn et al, 2008).
Resilience is generally considered to be an ability to manage challenges, stress, change, and pressure effectively, to cope and adapt successfully to adversity, and to return to balance after facing a major disruption in life or career (Leutenberg & Liptak, 2011). Burnout, on the other end of the spectrum, is a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment that occurs in response to job related stress and adversity (Schaufeli et al, 2001).
Gabbard (1985) describes the role of compulsiveness inherent in many physicians as a quality that is seen as necessary to be a good physician, but also as a trait that contributes to maladaptive behaviours that deplete a person’s wellness. The compulsive triad includes feelings of doubt, guilt, and an exaggerated sense of responsibility (Gabbard, 1985). This triad is cultivated in medicine where diagnostic uncertainty and human suffering is at stake (Gabbard, 1985). Despite these traits being adaptive and valued in the work setting, they come at a high personal cost, as they lead to inability to relax, reluctance to take time off, problems with allocating time to family, and an excessive sense of responsibility for things that are beyond one’s control (Gabbard, 1985). This style leads to personal feelings of hypertrophied guilt and feelings that one is being selfish in the pursuit of pleasure or healthy self-interests (Gabbard, 1985). The culture of medicine has shifted since the 1980s, and there is a growing understanding and interest in promoting wellness, balance, and resilience in medical trainees (Place & Talen, 2013). It is recognized that an investment in resilience education and training promotes healthier physicians who are better equipped to pursue sustainable careers in medicine (Place & Talen, 2013).
When one considers the demands of getting into medical school, completing residency training, and the routine exposure to traumatic experiences at work, it becomes unsurprising that burnout remains prevalent in physicians (Dyrbye et al, 2014). However, burnout is not a universal phenomenon, suggesting that there are factors which can modulate one’s development of burnout versus an ability to show resilience (Chaukos et al, 2017). The central aim of this module will be to discuss personal characteristics and coping styles that interact with external factors to contribute to a person’s wellbeing.
Coping strategies can be defined as specific actions taken to prevent or reduce adversity and the distress associated with adverse events (Carver & Connor-Smith, 2010). Multiple coping styles (or types) have been identified and each includes specific coping strategies (Carver & Connor-Smith, 2010). Some specific coping strategies also fall into more than one coping style (Carver & Connor-Smith, 2010). Some of these coping styles are described below (see also Table 1).
This style of coping involves taking steps to remove or evade the stressor, or to reduce the impact of the stressor (Carver & Connor-Smith, 2010). Specific coping strategies included within this are:
This style of coping is aimed at minimizing the distress that occurs because of a stressor (Carver & Connor-Smith, 2010). Specific strategies include:
Listed in Table 1 are two coping strategies that sound similar but are distinct. Venting refers to expression of negative feelings related to the problem (Carver, 1997). Emotional discharge refers to more impulsive actions like taking out anger on other people, doing something risky, yelling, or crying (Moos, 1995).
This style of coping is aimed at dealing with the stressor and related emotions (Carver & Connor-Smith, 2010). This style includes both problem and emotion focused coping (Carver & Connor-Smith, 2010). Specific strategies of approach coping include support seeking (either for empathy/reassurance, or for specific advice regarding the problem at hand), emotion regulation, acceptance, and cognitive restructuring (Carver, 1997; Carver & Connor-Smith, 2010; Carver & Scheier, 1989).
Distinction within this category has been made between primary control and secondary control coping (Carver & Connor-Smith, 2010). Primary control coping specifically refers to approach coping strategies that are attempts to control the stressor itself (Carver & Connor-Smith, 2010). Secondary control coping is also known as accommodative coping and refers to actions taken to adapt or adjust in the face of a stressor (Carver & Connor-Smith, 2010). Examples of this include acceptance, cognitive restructuring, and scaling back goals (Carver & Connor-Smith, 2010). Self-distraction, when done intentionally to adapt in the face of an uncontrollable stressor can also be seen as an accommodative coping strategy, though if done specifically to avoid dealing with the stressor would be considered an avoidance coping strategy (Carver & Connor-Smith, 2010).
This style of coping is aimed at escaping or avoiding the stressor and related emotions (Carver & Connor-Smith, 2010). Avoidance typically involves emotion focused coping styles as a problem focused style or strategy would generally involve approaching or engaging with the stressor or problem (Carver & Connor-Smith, 2010). Specific strategies include avoidance, denial, fantasy, wishful thinking, use of alcohol/illicit drugs/shopping/gambling to escape, and even relinquishing goals (Carver & Connor-Smith, 2010).
This style of coping can be viewed as falling under problem focused coping, emotion focused coping, and accommodative coping. It refers to the tendency for people to search for the benefits of stressful experiences in order to give the experience meaning (Carver & Connor-Smith, 2010). Specific strategies under this umbrella include reordering of life priorities, infusing ordinary events with positive meaning, and reappraisal (Carver & Connor-Smith, 2010). This style is more likely used when the stressor is uncontrollable or particularly severe (Carver & Connor-Smith, 2010).
Proactive coping occurs when strategies are used to prevent a threatening or harmful situation from occurring (Carver & Connor-Smith, 2010). They are typically problem focused (Carver & Connor-Smith, 2010). Specific strategies include accumulation of resources, and scanning for signs of a threat in order to take preventative action (Carver & Connor-Smith, 2010). This method can be particularly adaptive as it results in fewer stressful events and reduced intensity of stress in unavoidable situations (Carver & Connor-Smith, 2010).
| Coping styles | Problem focused coping | Emotion focused coping |
|---|---|---|
Approach (engagement) coping |
Active coping/problem solving
Planning Logical analysis Seek guidance + support (instrumental) Rumination Self-blame |
Positive reframing/reappraisal
Using emotional support Venting Self-regulation Controlled expression of emotion |
| Accommodative coping |
Acceptance
Cognitive restructuring Scaling back goals |
Intentional self-distraction |
| Meaning focused coping | Reordering of life priorities | Infusing events with positive meaning |
Avoidance (disengagement) coping |
Relinquishing goals
Resignation |
Cognitive avoidance
Denial Wishful thinking Fantasy Alcohol / drugs / shopping / gambling Relinquishing goals Mindless self-distraction Humour Religion Emotional discharge Behavioural disengagement (giving up) |
| Proactive coping |
Accumulation of resources
Scanning for signs of threat |
|
| This table draws from several articles to summarize various coping strategies and styles (Carver, 1997; Carver & Connor-Smith, 2010; Carver & Scheier, 1989; Moos, 1995). This matrix is an oversimplification of the distinctions in coping styles, however, it is helpful to conceptualize specific strategies within each style for the discussion in the text. | ||
While personality does have some impact on an individual’s preferred coping strategies and styles, it is not the only predictor of which coping strategies one will draw on in times of stress (Carver & Connor-Smith, 2010). Factors such as the context of the stress, the severity of the stress, a person’s age and culture are all important in allowing an individual to select particular coping strategies, but will also impact how effective that coping strategy is in dealing with the stressor (Carver & Connor-Smith, 2010).
In general, approach coping strategies tend to be more effective in reducing stress and also leading to better physical and mental health outcomes in research (Carver & Connor-Smith, 2010). This is untrue specifically of rumination, self-blame and venting, which lead to poorer physical and emotional outcomes (Carver & Connor-Smith, 2010). Avoidance coping strategies tend to predict development of anxiety, depression, disruptive behaviour, less positive emotions, and worse physical health (Carver & Connor-Smith, 2010; Tartas et al, 2016).
Though active attempts at problem solving are generally helpful in situations where the stressor is controllable, it is not helpful in situations that are uncontrollable and leads to increased distress (Carver & Connor-Smith, 2010). In these uncontrollable, unmodifiable situations, it is actually emotional approach coping (e.g., self-regulation, controlled expression of emotion) that is most helpful (Carver & Connor-Smith, 2010).
Self-blame specifically is a coping strategy that medical students have a tendency to use in pre-clinical years, but it also applies to resident physicians and practicing physicians as well (Fothergill et al, 2004; Tartas et al, 2016). Patient suicide in particular is a major stressor that can lead to development of post-traumatic stress symptoms, feelings of guilt, low self-esteem, intrusive thoughts of suicide, and reduced performance (Fothergill et al, 2004). Physicians who used support from a partner or colleagues (a problem and emotion focused strategy), as well as participating in recreational activities and holidays (i.e., seeking alternative rewards - an avoidant coping strategy) were able to effectively deal with stress (Fothergill et al, 2004).
Selection of appropriate and adaptive coping strategies is important in dealing with the numerous daily stressors encountered during residency training and practice. There is no specific guide on how to deal with every stress that one will encounter in professional and personal life. There is not even robust research indicating effective coping strategies to effectively manage common stressors. Repeated insults through various threats, harms, and losses take a toll on overall wellbeing and can lead to burnout (Carver & Connor-Smith, 2010; Fothergill et al, 2004; Lemaire & Wallace, 2017; Ruzycki & Lemaire, 2018). It follows that learning coping strategies to mitigate the harmful response to stressors and facilitate faster resolution would improve one’s wellbeing and also allow development of resilience, and the ability to bounce back from adversity (Carver & Connor-Smith, 2010; Gloria & Steinhardt, 2016).