tired doctor

Be resilient? what do you think I'm doing?

Doctors' Wellbeing
Seren Boyd

‘Resilience’ has become a loaded word. It is a quality everyone wants and needs, but is it right to tell doctors to be more resilient when their workplaces are at fault?

The class sits in silence, straight-backed, breathing deeply, feet on the floor, minds focused on the moment. The turmoil down the corridor can wait.

If anyone is going to convince health professionals they need resilience training, it’s Dr Farnaaz Sharief.

Unerringly cheerful, resolutely positive, she insists everyone can benefit from learning how to respond to stress, through simple techniques such as adjusting your breathing and posture.

Dr Sharief has honed her training sessions and proved their worth in some tough environments, including prisons and the Palestinian territories. And she first became involved in this field after coming close to burnout as a junior doctor in Zimbabwe, where she had huge responsibilities and scant resources.

She has been a GP for more than 20 years and was medical director of Medway and Swale health and care partnership during the pandemic. She has also won an MBE for a project providing free mental health support to her community in Kent.

Farnaaz Sharief facilitating
OUTREACH: Dr Sharief conducts collective resilience training

Mentions of mindfulness and meditation can raise eyebrows; she knows that. Yet, when she talks about the need for health professionals to build personal resilience, she is unapologetic. 

‘We work in a very tough, gruelling and brutal environment and it is not that we can ever get rid of the stress,’ says Dr Sharief. 

‘But one of the most powerful lessons I’ve learned in all this is that my mind is my responsibility, no-one else’s.’

For some, this is provocative talk. They find some of the wider conversation around ‘resilience’ unhelpful, misfocused. It requires context and strong caveats, they say. 

Consultant psychiatrist Andrew Molodynski is open about the fact he has come perilously close to burnout himself in recent years. It was only because his trust eventually took action in response to his and others’ concerns about workload that he didn’t resign. 

In a team, you just need one person who feels centred, focused, positive, because that spreads

Talk of resilience makes him sigh. His principal objection is that it puts the onus on the individual to be able to cope – rather than focusing on the myriad ways the system is failing the workforce.

‘[An] example I’ve seen of that is having psychologists feeding into teams in intensive care and acute medical admissions units,’ says Dr Molodynski, the BMA’s mental health lead. ‘It just makes my heart sink. It became quite common during COVID, which was completely understandable then, but a lot of them have carried on because they’re such difficult environments to work in.’

What made the difference in Dr Molodynski’s workplace was systemic change: a modest injection of funding to recruit more staff and substantially reduce the existing team’s workload. ‘In amongst that, we did have things like away-days, art-and-crafts classes, wellbeing packs and that kind of thing. And they were nice, they were helpful: I don’t laugh at them. But what properly changed things was systemic change.’ 

Stress hasn’t gone away, far from it. In psychiatry, for example, it’s the relentless moral injury of not being able to give people the treatment that they need. None of it is easily fixed – and Dr Molodynski doesn’t dispute that a degree of personal resilience is essential in medicine.

‘One wouldn’t want individuals to have no resilience at all. But the focus needs to be on reducing the toxicity of the health and social care system and working environment, rather than trying to artificially bolster people’s resilience to deal with a situation that is toxic.’

Wellbeing factors

Chris Turner doesn’t pull his punches in response to talk of ‘personal resilience’.

‘I know why we say it; I know why we want it,’ says the Midlands-based emergency medicine consultant. ‘But the evidence doesn’t bear out this belief that the more mindfulness and yoga and running I do, the more demonstrably resilient I will be.’

He cites the research of US haematologist Tait Shanafelt which concludes that personal resilience (‘what you can do for you’, as Dr Turner puts it) accounts for only about 20 per cent of our wellbeing at work. 

The organisational frameworks which either help or hinder people’s ability to do their work well, so-called ‘efficiencies of practice’, have a much greater effect on our wellbeing, Professor Shanafelt insists. Negative factors can be anything from poor staffing levels to an ineffective leadership team.

‘These are the pebbles in your shoes, the things that stop you being able to do your job well,’ says Dr Turner.

‘People hate not being able to do a good job, particularly in healthcare where patients suffer as a consequence. And that has a direct, measurable impact on our own wellbeing.’

Chris Turner
TURNER: No direct correlation between yoga classes and resilience

The other major contributor to wellbeing, according to Prof Shanafelt, is esprit de corps, roughly translated as our connection with colleagues.

‘It is the connection that we make with each other, and the sense that we make out of the job and the difficulties in doing that job,’ explains Dr Turner. 

‘Imagine I’m a scarecrow in the middle of a field, arms outstretched, being battered by the elements. I can work on my core strength and my deltoids, so I can keep my arms out for longer: that’s personal resilience. But eventually I’m going to be beaten by the weather, which represents what work is bombarding us with. 

‘In a culture of wellness, when I put my hands out, I’ve got one hand on your shoulder, the other on someone else’s shoulder, and you’ve both got your hands on other people’s shoulders, and so on, till we form a meshwork. The strength comes from connection.’

Broadly speaking, the ‘pebbles in our shoes’ are an organisational responsibility, whereas esprit de corps is collective, says Dr Turner. 

‘Of course, we’re doctors, and we’re obsessed with being as good as we can be individually, but it’s not enough. One of the problems with personal resilience is that if I break, if I burn out, and it’s my responsibility, I’ve failed me. But that’s not fair: the evidence says we are failed by systems which don’t allow us to perform at our best.

The focus needs to be on reducing the toxicity of the system and work environment

‘If you want evidence for this, the single most resilient specialty in hospital medicine in the USA is probably emergency medicine, Shanafelt says. And the single most burnt-out specialty in hospital medicine in the USA is emergency medicine.’

We need to reframe the debate, Dr Turner insists. ‘Personal resilience is not enough. We need to start to accept the collective and organisational components to this, and encourage cultures where people can flourish.’

Burnout and stress

Recognition of burnout among health professionals predates the pandemic but a slew of surveys and reports since COVID has confirmed it is ‘a widespread reality in today’s NHS’ (Health and Social Care Committee report, June 2021). 

Of more than 3,000 GP registrars polled by the BMA as recently as March, 72.9 per cent said they were experiencing burnout and stress. Last month, NHS England reversed its decision to cut specialist mental health support for secondary care doctors through NHS Practitioner Health, after an outcry, including from the BMA. 

COVID stretched the limits of human endurance – and it also showed us that human endurance is not without its limits. 

Dr Molodynski is clear that one of the main problems with the health service today is the ‘lack of a sense of team’, in stark contrast to the system in which he trained.

‘When we were junior doctors, people knew we had fairly crappy jobs, worked long hours for little pay, and they were generally sympathetic to us. I had a boss who would know me and look out for me, and I would feel a loyalty to them. A lot of that has broken apart with the way that care is arranged, particularly in acute trusts.’

Farnaaz Sharief.
OUTREACH: Dr Sharief conducts collective resilience training

There are points of light – the success of peer-support mentoring such as that provided by the BMA is a good example, he says – but change needs to be root and branch.

Dr Turner, who founded the Civility Saves Lives campaign, points out it is team leaders who should set the tone of mutual respect and support.

But leaders too need the wherewithal to be able to create environments where their teams can do their jobs well, he says. If leaders’ hands are tied, they risk becoming burnt out, cynical and emotionally distant from their teams, as a form of self-preservation. 

‘Empathy without the ability to make things better is just painful, and our natural response to this is to create barriers,’ says Dr Turner. ‘That’s when leaders can develop a form of toxic pseudo-resilience: they come to work every day but they no longer care because psychologically they cannot afford to.’

Andrew Molodynski
MOLODYNSKI: Came close to burnout

Resilience trainer and life coach Dr Sharief doesn’t dispute the need to focus on wider systemic pressures. But, for her, personal and collective resilience training are not mutually exclusive. 

And until the health service receives a huge injection of cash or fresh political thinking, there are things we can do to protect ourselves, she believes.

Dr Sharief’s retreats and training sessions for health professionals focus on simple techniques (see box, below) that help increase ‘energy levels and focus’. And she insists that individuals with strong personal resilience can positively affect the work culture and strengthen teams from the inside. 

‘In a team, you just need one person who feels centred, focused, positive, because that spreads. A lot of people come to us because they’ve seen the difference [training makes] in their colleagues and teams.

‘The first step in any redesign or programme should be: How are our teams? How are their minds? Before we talk about change, let’s focus on
the person.’

Online testimonials from healthcare workers of every grade and specialty who’ve had training through Dr Sharief’s not-for-profit, Manage Your Mind, certainly seem to bear this out. ‘Work hasn’t changed but we have,’ says one GP.

One of the problems with personal resilience is that if I break, if I burn out, and it’s my responsibility, I’ve failed me

Reinforcing positive new habits as a team is an important step towards reinventing team culture, she says.

‘I’d encourage practices, teams everywhere, to spend even just a few minutes together doing something to feel good, whether that’s a walk at lunchtime or some breath work before you start in the morning. 

‘It’s about being open and confident enough to say: let’s stop this and do something about it together.’

The four ‘F’s of resilience

Fuel: Eat healthily, keep hydrated.

Refuel: Get enough good-quality sleep.

Form: Change your form. Posture: sit straight, with feet on the ground, palms  facing upwards on your thighs, shoulders back, chin up. Breathing: try ‘box breathing’ and ‘straw breathing’: changing the rhythm of your breath helps manage your emotions.

Focus: Write down things you’re worried about, then focus on what you can influence.

Dr Sharief’s tips

Set small achievable goals:

  • Start by trying to instil a new habit (eg drinking two litres of water a day) for four days. Seeing the difference makes it easier to keep going.
  • Don’t just feel good, do good: Do something practical with your new energy and focus, eg build breaks into your morning, stop answering calls after 6pm.
  • Focus on little and often: Recharge regularly eg 10-20 minutes’ breathing exercises a day.