Maintaining Resilience in Today's Medical Environment: Personal Perspectives on Self-Care.

Background: The practice of medicine is becoming increasingly more stressful, owing to technological development, increased expectations, infrastructure deficiencies, lack of resources and healthcare systems that are struggling to cope in the face of the COVID-19 pandemic around the world. Objective: In this article, we explore ways to reduce stress and improve resilience in the work place in order to enhance wellbeing in the medical profession, but also ultimately to protect patient safety. Synopsis: We discuss attention to regular mealtimes, protected sleep and daily exercise, together with consideration of mindfulness, gratefulness, self-compassion, self-care and being part of supportive networks as ways to reduce stress.
Conclusion: While such techniques are not guaranteed to mitigate stress, psychology studies have shown that awareness of and attention to these components of a healthy lifestyle have the potential to reduce the adverse effects of increasing professional demands.

Ignoring the cumulative stress load that may impact all healthcare professionals in the current COVID-19 era may lead to errors of clinical judgment, burnout, reduced team effectiveness, poor communication with colleagues and patients, early retirement from clinical practice, or chronic physical and mental health issues, substance abuse and suicide. Apart from harm to the individual, ultimately patients suffer too. An American College of Surgeons survey found a marked adverse relationship between major medical errors, a surgeon’s mental quality of life, and all the three major domains of burnout: emotional exhaustion, “depersonalisation” (or detachment from the job) and a sense of low personal accomplishment or ineffectiveness.1 It should be noted that burnout is not technically the same as stress and cannot be cured by holidays or slowing down, although the terms are often confused. Recent findings do not support the view that burnout is first and foremost related to occupational-context factors and show that it is primarily accounted for by personality trait neuroticism.2

Many healthcare professionals believe that it is circumstance and work environment that are the main factors in reduced wellbeing at work and they themselves are passive players. Some ignore personal responsibility or “ownership” of the problem and the development of resilience to these issues is often overlooked.3 Systematic review and meta-analysis by West et al substantiate that both individual-focused and structural or organisational interventions can reduce physician burnout.3

Rosenberg suggests that the development of resilience should be considered a “process of harnessing the resources we need to sustain well-being”.4 Being in touch with strategies to prevent burnout, allows personal ownership of resilience and self-fulfilment.4 In this context, Cook-Cottone and Guyker have developed a very useful 33-item Mindful Self-Care Scale (MSCS) based on six areas: physical care, supportive relationship, mindful awareness, self-compassion and purpose, mindful relaxation and supportive structures.5

Based on our personal experience of working in the British National Health Service (NHS) (with over 60 years’ combined experience), and review of literature, we suggest eight personal habits or skills that should be considered in improving doctors’ wellbeing. This list is not exhaustive and there are other habits or skills that will improve doctors’ wellbeing. We have selected the following eight habits or skills, based on our experience. We appreciate that not all the suggestions will suit everyone and may not fit into daily schedules due to other demands, but starting with one or two items and then building up slowly should provide a platform to build resilience.

1. Diet and nutrition: A lack of regular breaks and irregular meal times has a significant negative impact on doctors’ personal wellness and professional performance.6 There is a strong relationship between nutrition and mental health in adults and this has been found to differ between depressed and anxious individuals.7 Taking regular meal breaks, eating healthily, especially with colleagues away from the clinical arena, rather than at a desk in front of a computer, promotes physical and mental wellbeing.7

2. Reappraisal of stress: When stress inevitably occurs, a greater understanding of stress management skills may be useful. Individuals who perceive that stress affects their health and report a large amount of stress have an increased risk of premature death, but individuals with high stress levels who do not perceive stress as harmful do not.8 This supports the idea that stress appraisal is critical in determining outcomes. We suggest that reappraisal can be considered by recognising physiological responses to stress as a positive phenomenon, helping to rise to the challenge, rather than a negative one in response to a threatening situation.

3. Sleep: Cognitively and emotionally, improved sleep leads to dose-dependent improvement in (1) the ability to focus and sustain attention, (2) working memory and long-term memory, (3) learning of complex skills, (4) the inability to discriminate the value of rewards with increased risk-taking and impulsivity, and (5) negative emotional reactivity and expression, mediated in large part by the impairment of the prefrontal cortical control over other areas of the brain.9 We suggest making a personal commitment to sleep 7 to 9 hours a night, whenever possible and to work around constraints: on-call activity, nightshifts, examinations and other acute demands. When deprived, owing to such demands, sleep time should be caught up as soon as is possible to maintain a healthy work-life balance.

4. Exercise: While the effect of exercise on physical health is well recognised, exercise also improves cognitive and emotional health. There is a growing body of evidence that shows the positive effects of exercise on mood state, such as anxiety, stress and depression through physiological, biochemical and psychological mechanisms.10 Increasing physical activities in daily lives does not need to come as a significant time or financial burden. Incorporating more walking and being active at work, when travelling to work and when at home can provide many benefits of exercise without additional demands.

5. Mindfulness: Evidence has shown strong benefits of mindfulness/meditation practice to wellbeing, resilience and adaptation to stressful situations. Benefit from meditation can be derived without an extensive time commitment. ESRT (Enhanced Stress Resilience Training) - a mindfulness-based training programme has shown potential benefits to wellbeing and executive function in the time-compressed and high-stake surgical training environment.11 As little as 13 min a day, if practiced daily, is beneficial.12 It is possible to use a meditation app for even a short meditation practice.

6. Gratefulness: Gratitude is the appreciation of what is valuable and meaningful to oneself and represents a general state of thankfulness and/or appreciation. Low gratitude states are related to impaired clinical functioning, whereas increased gratitude predicts wellbeing in psychological studies.13 The interventions to enhance gratitude can be classed into three categories: (a) daily listing of things for which to be grateful (journaling), (b) grateful contemplation (meditation), and (c) behavioral expressions of gratitude (writing or personally expressing them).

7. Self-compassion and self-care: Self-compassion in a simple way is “to replace harsh internal critics by a caring friend”. A mindful self-compassion program in a randomised controlled trial was also effective at increasing compassion for others, and enhancing other aspects of wellbeing. Benefits were present a year after completing the program.14 Another important aspect of self-care is to say “no”, when additional demands are placed that are detrimental.

8. Being part of supportive networks: Loneliness influences virtually every aspect of life. Enhanced social support, social skills development or increased opportunities for social interaction does provide some benefit, but a dedicated, facilitated program where a group of 6–10 physicians meet twice a month was shown to enhance engagement and reduce some domains of burnout.15 Volunteering, mentoring younger colleagues and joining hobby groups also provide opportunities to develop supportive network.

Conclusions

While there are no cast-iron remedies for stress in medical practice, considering at least some of the ideas we have suggested may allow some resilience to be developed in what is undoubtedly an increasingly complex profession. This is particularly important in the ongoing COVID-19 pandemic, which adds additional anxieties, related to healthcare systems being overburdened, under-resourced and understaffed.