Anthony Sanfilippo

Should Medical Schools be looking for it?
Should Medical Schools be teaching it?

What do professional sports teams, executive search firms and medical school admissions committees have in common? (This is not a trick question). Answer: they are searching for young people with the quality of resilience.

This particular quality may go by many names, both formal and colloquial: grit, perseverance, determination, truculence, tenacity, gutsiness. These are all terms for the quality perhaps best defined as “the ability to function in the face of adversity”. What professional hockey managers, headhunters and admissions committees have come to learn through bitter experience are three great truths common to their respective worlds:

resilence

Resilience, quite simply, is essential if the talented are to achieve success.

This is nothing new in the world or in human history:

Resilience is what has allowed communities and even peoples to survive and rebuild despite incredible suffering and losses.

Resilience is what got the British through the bombardments of the Second World War.

Resilience is what motivated so many of our ancestors to seek greater opportunities in this country.

Resilience is what our patients demonstrate as they endure their illnesses.

Resilience is what allows physicians to deal with stress, long hours, inability to “cure” every patient, and to function in a world that often fails to recognize or even acknowledge their efforts.

The lack of resilience has been cited as a major cause of “burn out” in students, residents and qualified physicians. So how can we characterize resilience in learners and practitioners of Medicine?

  • In a 2013 article, Zwack and Schweitzer (Academic Medicine 2013; 88:382) pose the intriguing question “If Every Fifth Physician is Affected by Burnout, What About the Other Four?” They conducted 200 interviews with physicians of various ages, disciplines and level of training who, upon assessment, were found to exhibit high levels of personal accomplishment and low levels of characteristics associated with “burnout” (emotional exhaustion, depersonalization). The analysis identified a number of factors these high functioning physicians shared, including gratification from the doctor-patient relationship and satisfaction from medical successes. These also exhibited what the authors called “resilience practices”, including leisure time activities intended to reduce stress, cultivation of contact with colleagues, good relations with family and friends, proactive engagement with the limits of skills and treatment errors, personal reflection, spiritual practices, and ritualized “time-out” periods in their schedules. They also identified a number of “useful attitudes”, including acceptance and realism, self-awareness and reflexivity, active engagement with limitations, recognizing when change is necessary, and appreciation of positive experiences.
  • Sarles and colleagues surveyed 141 general surgery residents and found that measures of “grit” were predictive of later psychological well-being (Am J Surgery 2014; 207(2): 251).
  • In their editorial to the Zwack paper, Epstein and Krasner (Academic Medicine 2013; 88: 301) point out that physicians are at particularly high risk, and therefore even more vulnerable. “All too often, busy clinicians ignore the early warning signs of stress – fatigue, irritability, and feeling outside their comfort zone – in the hope that the situation will self-correct or that their baseline adaptive skills will carry them forward”.
  • Angela Lee Duckworth, a PhD Psychologist at the University of Pennsylvania, has been studying the relationship between “grit” (defined as “the tendency to sustain passion and perseverance for long term goals”) and individual success. In “The Grit Effect: Predicting Retention in the Military, the Workplace, School and Marriage” (Eskries, Winkler, Shulman, Beal, Duckworth, Frontiers in Psychology 2014; 5: 36), she and her colleagues found that “grit predicted retention over and beyond established context-specific predictors of retention (eg. Intelligence, physical aptitude, Big Five personality traits, job tenure)…Grittier soldiers were more likely to complete an Army Special Operations Forces selection course, grittier sales employees were more likely to keep their jobs, grittier students were more likely to graduate from high school, and grittier men were more likely to stay married.”

All well and good, but can anything be done for the resilience-deficient? One might imagine that resilience is an inherent quality determined by one’s genetic makeup and therefore beyond learning or development. Apparently not.

  • Sood and colleagues tested the utility of a resiliency training intervention consisting of single 90 minute one-on-one interactions among their colleagues in the Department of Medicine at the Mayo Clinic (J Gen Intern Med 2011; 26: 858) and found significant improvements in a number of measured wellness parameters, including resiliency, perceived stress, anxiety and overall quality of life.
  • Gail Wagnild is both a Registered Nurse and PhD psychologist who has been promoting the concept that although we can’t avoid adversity in our lives, we can choose how to respond to such events in a way that promotes personal resilience. In “Discovering Your Resilience Core”, she describes five essential characteristics of resilience (purpose, perseverance, self-reliance, equanimity, and existential aloneness) and how each can be identified and strengthened.

So it appears the answer to the two questions I posed are “yes”, and that resilience is not only something that can be recognized, but also developed. Given its importance to career success, it would seem advisable for medical schools to both recognize it as an attractive (maybe essential) applicant quality that should be actively searched out, and also promote it’s further development in our students.

Admissions committees will have long debates about which personal qualities are the most relevant to career success. I vote for resilience.