The first rule of covering a hurricane? Get footage of palm trees bending to the storm. They sway, arch, bow through 50 degrees, then rebound like elastic to recover their form and position. Cars and pylons cartwheel and buckle in the tempest. But with its heavy root network, its trunk a cable of bundled fibre and fronded leaves that fold up, the canny, durable palm has worked out how to ride a storm by flexing, without falling over.
Resilience has attained treasured status in general practice’s belief system since our specialty’s popularity, resourcing, and recruitment began to head south, along with the banks, after 2008. Like an advanced stage of enlightenment, it has become the key attribute for anyone wanting to survive and thrive as a GP in today’s harsh NHS environment.1
That GPs work hard and long, in tough conditions, mostly alone with their patients; that they are exposed to distress and tragedy through their working lives; that they carry formidable responsibilities, and hold unbearable secrets, is not news. Being resolute, courageous, of a calm temperament, committed, able to go without sleep, face abuse and the threat of violence, yet remain open minded and kind — all these are taken as read in a good GP; and that’s before you get on to being up to date, a patient listener, and a smart decision maker. Bags of emotional intelligence and great interpersonal skills make up the full kit list.
We embrace the description ‘resilient’ as a sex- and judgement-free upgrade from some of its heroic predecessors: robust, strong, upright, detached, devoted, selfless. GPs no longer need to resemble a rock or act like a martyr. ‘Resilient’ evokes notions of flexible, irrepressible, assertive, organised, humorous, team-minded, hardy, adaptable, assured, compassionate, buoyant. Two things help to keep resilience grounded and to shield it, in part at least, from the psycho-jargon some would wish on it.
WHAT DOES RESILIENCE LOOK AND FEEL LIKE?
First, it breaks down into a useful set of component attributes that intuitively ring true. Resilient people typically commit to some greater purpose in their lives; focus on what is in their gift and disregard what they cannot control; and see difficulty as a chance to get on, not as a personal threat. They resist their perfectionist traits, and learn that it’s less stressful to get the most important tasks done first. They tend to view set-backs as temporary, limited to specifics, and not directed at them personally.2–4
Second, some of its attributes may be acquirable. Personal resilience can, it appears, be learnt. If GPs could just wise up and train to become more resilient, what a godsend that would be for the person in charge of a health service haemorrhaging GPs in their thirties to Australasia and GPs in their fifties to retirement. The NHS was quick to see how it might shift the spotlight on to doctors and nurses, by encouraging them to fess up, get a grip, and learn to be resilient as a route out of trouble. The NHS General Practice Resilience Programme,5 which forms part of the General Practice Forward View,6 drew criticism (‘Doctors need to be supported, not trained in resilience’) for paying too little attention to structural, strategic interventions that would help practices develop organisational resilience.7 But there is value in developing personal resilience, while also remaining wary of those who would have you just do the training and jump back into the fire.
Consider. You are a new, part-time GP, working 2 days a week in a well-regarded training practice. For these reasons you picked it — from a choice of several available to you, such is the weather in general practice at the moment. You have decided not to work nights or weekends to preserve your work–life balance. Your partner works full time and is often away from home overnight. Three months in, 8.30 at night, sore eyed from scrolling through screens of results about patients you don’t know, hungry and cold, you realise that your job is lonely, frightening, and dull. At that moment you definitely do not feel resilient. Your head tells you this feeling is likely to pass; that there’s lots else going on in your life; and that it’s the system, not you, at fault. But the chilling feeling remains a fact.
TRAINING FOR RESILIENCE
One road to resilience is to treat it like personal fitness and go to the gym. Techniques are out there if you can stick the jargon and work through the babble.8
Mindfulness; online resilience training; stress management tools for rhythmic breathing and self-generated positive emotion to achieve greater heart rate variability, which is a physical sign of reduced stress; self-help books on how to become more self-aware, live in the moment, avoid learnt helplessness, maintain a good sense of meaning and purpose, make your work fit your values, and keep home a sanctuary. Then there are the simple — code for easy to say, hard to do — habits for daily life: enough sleep, exercise, affection and intimacy, eating well, staying in touch with friends, and keeping interests and hobbies alive. What limited evidence there is on whether training can enhance resilience suggests that it confers a modest, but consistent, benefit for the athlete.9 Training is tactical, personal to each doctor. It can work, but only so far. It plays a small part in the greater scheme of things. A practice needs also to create a resilient environment.10
NOT JUST THE PROPERTY OF THE INDIVIDUAL
The article in this month’s BJGP by Liz Walton and colleagues reports on a qualitative study of 23 GPs working in areas of multiple deprivation in Yorkshire, in Northern England.11 They were asked how they maintained, and dealt with challenges to, their resilience. Two of the emergent themes — being able to flex and adapt, and keeping a proper work–life balance — were familiar from previous studies. But they also identified a third theme: that the resilience of these GPs depended on the team and the organisation, and was not just a property of the individual. How well the practice team functioned determined how resilient its constituent members felt. This is the usual mantra reverse-engineered: conventional talk was of how a team’s success would depend on each player performing well.
One doctor in the study began to thrive after changing practices, having previously felt unable to cope. The clinical aspects of the work at both practices remained virtually identical. Her new-found resilience came from knowing there was support from the team. Another said that if everyone had just stayed in their rooms and not been happy to talk or listen when she wanted advice, she definitely would not have stuck around. And it’s simple stuff they cited: having lunch together, making the chance for a chat, helping the duty doctor out when you see them ‘drowning’.
In the current landscape of general practice, more doctors are part-time, more are salaried, more are locums, and fewer are partners owning premises and employing staff. This environment tends to make time together and feeling you belong harder. Teams need active cultivation. The message to doctors planning to join a new practice is to look in detail at how the team works. Rather than beating themselves up for feeling lonely, disillusioned, and scared, practical changes — a protected half-hour for morning coffee, for example — could unlock their resilience.
CONCLUSION
The message to established GPs and their managers when they recruit is that their new young colleagues’ resilience will depend on — indeed will be a direct function of — their success in running a team whose members do more than gather under a common roof. When doctors work as a pack, the doctors and the pack will thrive.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The author has declared no competing interests.
- © British Journal of General Practice 2018