Resilience: what is it, why do we need it, and can it help us?

WHAT IS RESILIENCE?

When we are stressed we find it much more difficult to empathise with family and strangers as our stress responses turn off compassion and empathy.⁶ Unstressed doctors are safer and better at their job.⁷

There are many definitions of resilience but it is best considered as the individual’s ability to adapt to and manage stress and adversity: essential qualities for GPs. Our responsibility is to maintain compassion and manage complex, day-to-day, clinical, and managerial situations successfully. While the NHS needs to transform we too have a duty of care to protect primary care’s vital human capital: ourselves and our staff.

Close face-to-face contact with suffering is instinctually disturbing. When we feel resilient, a clinical encounter will trigger an appropriately caring response;⁸ but if we are feeling stressed, struggling with our own emotions and exhausted, the same meeting is likely to evoke threat-avoidance reactions. This becomes all the more pronounced against a backdrop of turbulence from paperwork, partners, targets, and finances.

Initially, unrelenting sympathetic system arousal makes us more emotionally labile and narrows thought processes down to the few needed for threat avoidance and goal seeking. Ultimately this triggers pro-inflammatory pathways and immune dysfunction. Gradually, as it de-tunes the way that our unconscious ‘mirroring’ pre-motor cortex sensitises us to other people’s expressions and gestures, it make us less empathic and perceptive (burnout stages 1 and 2). This ‘dumbing-down’, although it might protect us through ‘professional numbing’, has obvious downsides for patient-centred care and safety. Unless there can be respite from the remorseless bodily processes of arousal and struggle, the body and mind will eventually defend against perceived overwhelm by shifting into freeze-dissociation (burnout stage 3).⁹

WHAT MAKES A GP RESILIENT?

Resilience is not a static trait that some have and others lack. Nature and nurture play a part but it depends greatly on circumstances, knowledge, skills, and attitudes. The claim that modern GPs lack resilience deflects the blame from a broken system onto the individuals working within it. In fact GPs have shown themselves to be inherently resilient, readily adapting to shifting work requirements. Indeed, traditional primary care practices, managed and run by GPs, are so resilient that even in the face of the current adversity they outperform commercially run alternative providers.¹⁰

Five personality traits correlate strongly with GPs’ resilience because they facilitate safe adaption: self-directedness, cooperativeness, harm avoidance, persistence,⁹ and general wellbeing.¹¹ Charney and Southwick identified 10 factors associated with stronger resilience (Box 3).¹²

HOW CAN WE DEVELOP RESILIENCE IN PRIMARY CARE?

The system is unlikely to change fast without political debate so how can we develop ‘resilience’ skills that will sustain us? Resilience involves effective adaptation, learning through adversity, and bouncing forward. One kind of exhausted response is protective withdrawal while we wait for system change; another is to become change agents. The research literature supplies examples of self-care techniques that enhance self-regulation and improve work efficiency, such as: regular breaks, mindfulness, co-mentoring, positive psychology, and biofeedback training. Employing these techniques could help us maintain our capacity to care, engage, and resist further damage to the NHS.

CONCLUSION

General practice is the cornerstone of the NHS. It makes the NHS sustainable, dealing with 90% of the work on less than 8% of the budget. The extraordinary changes that have taken place over the past 5 years mean that the crisis in general practice now threatens the very existence of the NHS. The Rowland Report¹⁴ was tasked with examining new models of care, aiming to deliver services for the future. This could radically change the GP’s role from personally providing hands-on comprehensive care, to one in which there is more focus on coordinating and supervising others to perform that task. GP numbers and maintaining the GP workforce were never part of its remit but clearly these changes could impact on both.

It is disappointing that the need for a strong workforce of motivated and engaged GPs, which is crucial for the recommendations of the Rowland Report to stand any chance of success, was not highlighted more prominently in that report. We hope that the forthcoming government inquiry into patient demand and access, workforce, and funding will better address these issues.¹⁵

Meanwhile, we need to work with our colleagues and patients to effect change and alter the negative public stereotypes that provide a smokescreen for the slow, covert destruction of our publicly funded healthcare system. We need to sustain ourselves while solutions are found by finding ways of boosting our resilience and improving our working environments.