Physician wellness

Coping with the stress of medical practice

Residents and resiliency

Originally published November 2016
W16-005-E

While all physicians need to be resilient in the face of increasing patient and health system demands, the unique challenges facing resident doctors means they should not lose sight of their physical and mental health as they take on new roles and responsibilities at this stage in their career. The combination of learning, patient care, skill development, teaching, research, and personal and family responsibilities can be onerous, and residents need skills and capabilities to remain resilient and healthy.

Resilience

Resilience has been defined as "…the ability of an individual to respond to stress in a healthy, adaptive way, such that personal goals are achieved at minimal psychological and physical cost."1 It is the capacity to manage stress and difficulties in the most positive manner possible. In the healthcare context, resilience is also important in helping to avoid burnout and depression, and to provide good, safe patient care.

In the Royal College of Physician and Surgeons of Canada’s CanMEDS 2015 Physician Competency Framework, the "professional" competency states that physicians have "Applied capacity for self-regulation, including the assessment and monitoring of one’s thoughts, behaviours, emotions, and attention for optimal performance and well-being," and "Resilience for sustainable practice."2 This highlights the importance of physician health and the requirement that doctors have the necessary skills and abilities to enjoy long and satisfying careers while providing safe medical care.

Residents are facing new duties and obligations, often in new settings with new people, and need to be particularly mindful of their physical and mental health. Physician residents should also be aware of the actions they can take to maintain their well-being.

International research published in the Journal of the American Medical Association in December 2015 indicated nearly one-third (29%) of resident physicians screened positive for depression or depressive symptoms.3

Recognizing difficulties

Physicians must recognize how and when they are adversely affected by pressure, and then find strategies to strengthen their resilience.4 This may require doctors to reflect on their situation and reactions to stress, and make an honest appraisal of their thoughts, feelings, and stress levels. This self-awareness allows physicians to proactively address stressors, workload issues, feelings of isolation, or other factors affecting their resilience. Some experts suggest self-monitoring5 and mindfulness6 as ways to identify potential problems and begin addressing resilience.

Enhancing resilience

Each resident will have different ways to manage his or her stress and enhance resilience. Howe identifies positive resilience coping mechanisms such as seeking social support, managing negative emotions, using reflection for learning, and using moral beliefs for self-motivation.7 Other strategies to strengthen resilience might include maintaining healthy attitudes toward work, developing self-awareness, recognizing and accepting personal limitations, nurturing interests outside of work, maintaining healthy personal and professional relationships, and balancing work and family life.8 Zwack notes that "…a well-diversified pool of social resources and fields of interest, together with realistic expectancies and good self-knowledge, will support sustainable coping."9

Resilience has been described as both an individual and community trait. If this is the case, physicians should consider both offering and accepting support. As the medical professional culture has traditionally advocated self-sufficiency, it can be difficult for doctors to accept help or to work with others to solve problems.10 This is changing. Residents should consider sharing their problems, concerns, or challenges with peers, mentors, family members, or healthcare professionals to find coping strategies and solutions.

Other studies suggest that resilience can "…be applied to teams and organizations, and not just to individuals."4 This can develop "…through mutual trust and the strong ties they forge, enabling them to cope with difficulties and adversity together."4 Accordingly, residents may wish to explore how they can draw strength from the healthcare providers they work with, and how to strengthen the resilience of the care team. For example, debriefing after significant clinical, patient safety, or work-related events may help all providers, including residents, cope with the situation.

The reality is that clinical residency is challenging and demanding. Yet, in spite of the limitations imposed by their work, physicians are reminded to make deliberate efforts to take care of themselves and maintain social ties outside of work. They are encouraged to identify resiliency strategies and adopt those that work best for them. Even some of the prevention basics can be helpful, such as good nutrition, exercise, and rest. Residents should also remain confident in their skills and abilities to adapt to adversity and overcome challenges.

Resiliency training

Resilience is not a trait that people either have or do not have. It involves learning and developing behaviours, thoughts, and actions.11 Specific resiliency training often refers to developing skills to effectively identify, cope with, and recover from challenging experiences. Skills-based resiliency training can help residents mitigate stress, overcome adversity, and use tools to better support their patients and their peers.12

Resident Doctors of Canada is working to develop a tailored curriculum to improve mental resiliency in resident doctors. "Residents will learn to identify early signs of distress and relevant early interventions, apply evidence-based skills to improve performance in challenging work environments, and recognize when and how to seek support."13 Their end goal is a well-rounded and healthier physician who is a resource to others in difficulty and who can provide better care to patients.

Getting help

Residents should reflect on their levels of stress, their perceived resilience, and whether they need to seek assistance. Talking to peers, supervisors, or university program directors; seeking support from their hospital or health authority; or contacting their resident association or federation can be helpful. The Canadian Physician Health Institute and provincial and territorial medical associations also have relevant resources, and most provinces and territories have physician wellness program available to residents. Often the university has supports for residents who are finding it difficult to cope. Community health resources are another option. And certainly, residents should not be reluctant to get help or access the healthcare system for their own health needs.

CMPA members can also call the Association if they require advice or assistance with any medical-legal issues that arise from their professional work in Canada. Our experienced physician advisors are also familiar with physician health issues. Members may also wish to consult the CMPA Good Practices Guide >Adverse Events>Managing stress.

 
 

References

  1. Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med [Internet]. 2013 Mar [cited 2016 Jan 20];88(3):301-3. Available from: http://journals.lww.com/academicmedicine/Fulltext/2013/03000/Physician_Resilience___What_It_Means,_Why_It.12.aspx
  2. Frank JR, Snell L, Sherbino J, editors. CanMEDS 2015 Physician Competency Framework [Internet]. Ottawa (ON): Royal College of Physicians and Surgeons of Canada; 2015 [cited 2016 Jan 21]. 17 p. Available from: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf
  3. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Angelantonio E, Sen S. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA [Internet]. 2015 Dec [cited 2016 Oct 24]; 314(22):2373-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26647259
  4. Roman S, Prévost, C. Physician health: state of knowledge and preventive approaches [Internet]. Montréal (QC): Programme d’aide aux médecins du Québec:2015 [cited 2016 Oct 24]. 35 p. Available from: http://catalogue.cssslaval.qc.ca/GEIDEFile/Doc_224290_ang.pdf?Archive=102463592064&File=Doc_224290_Ang_pdf
  5. Fry H, Kneebone R, editors. Surgical education: theorising an emerging domain. New York: Springer; c2011. Chapter 10, Self-monitoring in surgical practice: Slowing down when you should; p. 169-82.
  6. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected… a key to my survival". JAMA [Internet]. 2009 March [cited 2016 Oct 24]; 301;11:1155-64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19293416
  7. Howe A, Smajdor A, Stöckl A. Towards an understanding of resilience and its relevance to medical training. Med Educ [Internet]. 2012 Mar 16 [cited 2016 Jan 20];46(4):349-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22429170
  8. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician [Internet]. 2008 May [cited 2016 Jan 20];54(5):722-9. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377221/
  9. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med [Internet]. 2013 Mar [cited 2016 Jan 20];88(3):382-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23348093
  10. Longnecker R, Zink T, Florence J. Teaching and learning resilience: Building adaptive capacity for rural practice. A report and subsequent analysis of a workshop conducted at the Rural Medical Educators Conference, Savannah, Georgia, May 18, 2010. J Rural Health. 2012 April; 28;2:122-27.
  11. The Road to Resilience [Internet]. Washington (DC): American Psychological Association. [cited 2016 Jan 21]. Available from: http://www.apa.org/helpcenter/road-resilience.aspx
  12. Resiliency Training [Internet]. Ottawa (ON): Resident Doctors of Canada. [cited 2016 Jan 21]. Available from: http://residentdoctors.ca/wellness/resiliency/
  13. The Resiliency Curriculum Project [Internet]. Ottawa (ON): Resident Doctors of Canada. [cited 2016 Jan 21.] Available from: http://residentdoctors.ca/wp-content/uploads/2015/08/Resiliency-Focus-Group-Meeting-Summary-06-27-28-15.pdf

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.