Test of resilience: Leadership examines challenges facing medical students

By Patrick Wascovich

Dr. Blake Barker, an Associate Dean for Student Affairs at UT Southwestern Medical School, posed a deceptively simple admissions question: Should faculty committees at academic medical centers be looking for perfect students, or resilient ones?

Dr. Barker’s Internal Medicine Grand Rounds presentation titled “Grit and Resilience in Learners” provided plenty to contemplate. Postgraduate students who have never experienced failure often do not know how to deal with it and may have negative reactions when encountered, while resilient students may sustain themselves through challenges during the first and second years of their medical education – when instruction is routinely delivered at a breakneck pace – before finding their stride.

Physicians who are resilient:

  • Practice gratitude
  • Celebrate victories
  • Cultivate relationships with patients and with colleagues
  • Engage in negative aspects of their practice by seeking solutions
  • Take part in professional development

Source: Dr. Blake Barker

“We want our physicians to be people who can rise above adversity. We want them to be competent and great communicators, but with staying power,” said Dr. Barker, an Assistant Professor of Internal Medicine. “But we need to remain focused on outcomes. The standard I personally apply is ‘What I would expect from a physician that cared for my family?’ ”

Often one of the necessary ingredients is learning in the medical environment is how to positively adapt to stress, which if not addressed and managed can lead to poor coping and eventually to burnout. Dr. Barker said these negatives can be countered methodically with grit and resilience.

Although medical trainees used to routinely work more than 100 hours each week, there was only one published study on student burnout prior to 2005. Since then, studies on the subject have reported that about 49 percent of U.S. medical students have experienced at least one characteristic of burnout by graduation, and 60 percent of residents have experienced it at some level by the end of their second year (with depersonalization of patients being a common experience, and internal medicine trainees reporting more errors as a leading result).

Stress also was a subject of a recent UTSW faculty town hall, at which results of a UT Southwestern Medical Group faculty survey on burnout and the steps to address these issues were discussed.

“Burnout is prevalent among physicians nationwide and is a growing problem,” said Dr. David Johnson, Chairman of Internal Medicine. “Addressing the problem is a major priority of our Department and the institution, and understanding the personal attributes that may lessen or increase the potential for burnout among our trainees is helpful in this effort.”

Dr. Preston Wiles, Professor of Psychiatry and Medical Director of the Student Wellness and Counseling Center as well as the new Residents Wellness Center, said, “Every year of [medical] education and training is stressful, but the first years of residency are especially so. For residents, it’s the first time your name is on the medical order, and you are making decisions. Although there’s supervision, there’s a lot of responsibility, fatigue, exhaustion, time-management issues, and adjustments to working within a team environment.”

Burnout effects can include emotional exhaustion, cynicism toward work, depersonalization of patients, less effectiveness, and low professional accomplishment. Among the nation’s clinicians, the highest levels were reported in emergency medicine, general internal medicine, neurology, and family medicine.

“That’s particularly concerning, as those are the some of the front-line medical specialties that see the most patients,” Dr. Barker said.

In the past few years, the Association of American Medical Colleges, the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and the National Academy of Medicine have adopted official positions on the well-being of students, trainees, and clinicians.

Which brings us back to the perfect vs. resilient student quandary.

The former, Dr. Barker said, may have been a straight-A student all through college but has never experienced an educational challenge or setback. Dr. Angela Lee Duckworth, a Professor of Psychology at the University of Pennsylvania, famously calls such students “the fragile perfects” because previously they have always won. Her TED talk on the subject has been viewed more than 7 million times.

On the other hand, studies over the past decade have shown that the latter student’s experience of trying and occasionally failing can provide a more stable foundation for learning. Non-white medical students, for instance, often can handle stress better than their classmates.

“They have been shown to be more resilient,” Dr. Barker said. “That may be because they have faced and have overcome many more challenges to get into or through medical school, but as yet there aren’t enough studies that have been done to prove this.”

Stress, in fact, often helps in professional growth, Dr. Barker said. In a study at the Icahn School of Medicine at Mount Sinai in 2006-2007, medical students and trainees completed reports and on average the mean number of traumatic life-and-death events experienced was two per student, with negative non-traumatic occurrences at 3.2 per student. “By learning how to handle stress and trauma, we accumulate the experiences needed to be applied in future situations,” he said.

Students with grit, he said, often develop into clinicians who are resilient. “Gritty people have passion, but also identify areas that might seem to be boring but that are effective,” Dr. Barker said. “They make their workplace a good place to be.”

Some habits that resilient physicians have, Dr. Barker said, include knowing and accepting their limits, setting boundaries, taking the time to stretch, and taking breaks.

“In general, the things that they tell their patients to do to be well they are doing themselves,” he said.

Dr. Johnson holds the Donald W. Seldin Distinguished Chair in Internal Medicine.

Dr. Wiles holds the Drs. Anne and George Race Professorship of Student Psychiatry.