Over the last six months, I have had the opportunity to interact with over 300 residency programs and medical schools about wellness of their trainees. A vast majority of program directors and faculty expressed how over half of their residents and over a third of their medical students had at least one component of burnout syndrome. More than a dozen residency program directors confided in me that they had a recent resident suicide in their institutions.
So, you can imagine I was somewhat surprised that many programs and institutions still don’t incorporate proactive training like resilience exercises in their wellness initiatives. I believe that resilience training should be an integral component of ALL wellness initiatives. As resilience expert and author of The Resilience Factor, Dr. Andrew Shatte said, “More than education, more than experience, more than training, it is RESILIENCE that determines who succeeds and who fails.” Resilience empowers residents and medical students to overcome obstacles and challenges, steer through day-to-day adversities and bounce back from major setbacks. Resilience proactively builds the critically important skills necessary to help prevent burnout and depression. Cognitive behavioral therapy (CBT) research shows that everyone is capable of becoming more resilient if they have willingness to change – a process that begins with self-exploration.
Building resilience takes deliberate practice beginning with learning the “A-B-Cs” of cognitive therapy. Most people think that there is a direct connection from an adversity (A) to a consequence (C) that cannot be controlled. Can an adversity occur that automatically leads to a consequence? The answer is no! There is always a belief (B) or thought process in between the A and C that has a direct impact on the resulting consequence (the feelings, behavior and actions). If an A led directly to a C, everyone would react to an adversity in the exact same way. But that is of course not how it happens. Everyone reacts differently because everyone has unique thinking processes and patterns.
Let me illustrate how different Bs can lead to unique Cs in an example below.
A= Adversity (Stressor)
Example: You are on-call and you are getting paged every few minutes about another patient being admitted to your service. This is turning out to be the busiest call you have ever had.
B= Belief (Thought Process)
Example 1: “I cannot deal with this and I am not confident things will work out; there will be so many patients that I’ll make mistakes. A patient will die and that will be the end of my medical career.”
Example 2: “Yes, there are a lot of patients at once, but I can ask for help and do the best I can. I can learn new organization skills to handle this challenge, because it is not unlike what I have done before. This on-call night will be one I will remember, and it’s going to turn out just fine.”
C = Consequences (Feelings or Behaviors)
C resulting from the belief in example 1: The trainee is highly stressed and takes a disorganized approach to the on-call challenge. This distressful consequence is a result of a type of cognitive distortion known as catastrophizing where one assumes the worst, most catastrophic outcome possible rather than assuming the most likely (a more neutral or positive) outcome.
C resulting from the belief in example 2: The trainee is more likely to appropriately cope with the situation with an acceptable stress level and creative use of support services for processing patient admissions. Note how the thought content invokes reason and problem solving, unlike the dysfunctional, stress-inducing thought-stream in the first example.
Now you can understand how the A-B-C model can help explain how we react to different types of adversities. As trainees get more in tune with their thinking, they might detect some emerging patterns. They may begin to realize that there are some consistent connections between their B and C as described in the table below.
|Beliefs (B)||Consequences (C)|
|Violation of your rights||Anger|
|Real world loss or loss of self-worth||Sadness, depression|
|Violation of another’s rights||Guilt|
|Future threat||Anxiety, fear|
|Negative comparison to others||Embarrassment|
This understanding leads to insights in their thinking patterns. This creates opportunities for trainees to change their thinking patterns to improve their consequences or outcomes.
Teaching oneself to adopt new ways of thinking is not only possible based on cognitive behavioral methods, but also based on the neurophysiologic model of resilience. Research on post-traumatic stress, depression, and differences in resilience teach us that improved coping is related both to neuroplasticity and to developing new neuropathways and different, more adaptive and helpful ways of viewing stress. The overall objective of resilience skill-building is to harness one’s innate cognitive flexibility, leading to the ability to reappraise negative situations.
As Henry Ford said so clearly and succinctly, “Whether you think you can, or you think you can’t – you are right.”
In the CoreWellness program, there are several proactive resilience skill-building exercises for residents and medical students to help them better deal with adversities and improve their consequences resulting in more realistic and optimistic beliefs. In this way trainees learn to not only survive their training, but to actually grow and flourish both professionally and personally.
Please let me know if there is anything I can do to help you, your department, or your institution build resilience. You can reach me at email@example.com. I look forward to interacting with you.
Jeffrey Levy, MD
Developer of CoreWellness Online for Residents
Author of CoreWellness: A Physician Wellness Program
About Consulting Services
Dr. Jeffrey Levy, author of CoreWellness: A Physician Wellness Program and Dr. Catherine Pipas, author of A Doctor’s Dozen lead a team of physician wellness experts to provide consultative services including train-the-trainer programs for faculty development to improve the faculty’s ability to facilitate wellness discussions and create a culture of wellness. Other longer-term consultative engagements include guiding departments and/or institutions through a step-by-step process to design, launch, measure, sustain and improve their wellness initiatives.