Dr Ayman Shenouda
When each of us experience hardship, it changes us - yet not all of us experience lasting harm as a result. Stress affects people differently with many factors influencing the strength of our stress response.
Resilience is our capacity to overcome adversity and our resilience is shaped by our experiences – both good and bad. And it’s really only when you’re faced with extreme stress that your level of resilience can be determined.
‘You only know what you are made of when you are broken.’
This was the moving statement from a father who lost his unborn baby during the recent Grenfell Tower inquiry.
It is said that we can all overcome adversity and choose to be resilient. But how can we increase emotional resilience and cultivate more resilience for ourselves and for others?
Neuroplasticity and resilience
Can neuroplasticity help us to understand resilience?
Mindfulness sites are full of the promise of rewiring your brain through neurally inspired therapies to increase emotional resilience.
Brain researchers reassure us that the brain can change and that brain reorganisation is not limited by age. That it is the brain’s plasticity that can help us to overcome adversity.
Neuroplasticity is the brain’s ability to grow and change in response to experience. It is supported by chemical, by structural and by functional changes across the whole brain and together they support learning.
What is it that limits and facilitates neuroplasticity?
Dr Lara Boyd Neuroscientist and Physical Therapist at the University of British Columbia explains this well in her work which looks at what can be done to help patients recover from stroke.
In looking at how we learn she states that the best driver of neuroplastic change in your brain is your behaviour. But that it needs practice and you have to do the work with increased difficulty leading to more learning and greater structural change.
Our uniqueness holds the key
Dr Boyd’s research has looked to therapies that prime or prepare the brain to learn – brain stimulation, exercise, and robotics. But she also states that a major limitation is that patterns of neuroplasticity are highly variable from person to person.
It is this variability in studying the brain after stroke that she believes provides some valuable transferable lessons. Learnt neuroplasticity after stroke applies to everyone. It is these individual patterns and variabilities in change that allow us to develop new and effective interventions.
It is partly personalised medicine with each individual requiring their own intervention. However, this concept is then broadened through embracing our uniqueness with personalised learning being key.
This research shows that biomarkers are helpful to match specific therapies with individual patients. More specifically it is a combination of biomarkers that best predicts neuroplastic change and patterns of recovery after stroke.
Applying this learning
Dr Boyd’s advice is to study how and what you learn best. Repeat those behaviours that are healthy for your brain and break those that are not.
In applying this learning, it is clear that resilience can be taught. But it requires supportive relationships and opportunities for personalised learning.
Bringing this back to our own workplace, how can we harness the brain’s innate capacity to change? Not only in our patients and ourselves but applying this knowledge in equipping our trainees with strategies to cope in dealing with stress.
Resilience in the workplace
I think it is important to look at how can we inspire resilience in others. Working through what strategies work for the individual is important but so is providing a workplace free from harm, neglect, and disrespect.
More emphasis on building positive work environments, coping strategies and the importance of self-care is needed. Training in neuroplasticity and how to exploit it should be part of our armoury.
For our trainees, we need to think more about building their stress fitness and coaching and mentoring are helpful in developing this resilience. Trainees would benefit from a buddy and a mentor to improve resilience and this needs to be formalised in our training system.
Funding for formalised training programs to improve resilience in our trainees should also be prioritised. Webinars in workplace wellbeing, resilience, mindfulness, cognitive reappraisal training should all be pursued.
Resilient people are able to see things from others perspectives. They also tend to value others.
Simply conversing in a compassionate way changes the brain.
Coming back to neuroplasticity, if we repeat certain throughs or behaviours often enough the neural pathway can be created. Forming new connections and weakening those patterns that are not working for you being key.
In mastering resilience, we know that much of it has to come down to the individual and effort. Fixing a self-critical neural network is doable but takes practice and training to chart new pathways.
In untapping resilience by harnessing the brain’s innate capacity to change we must prioritise the tools proven to bring about these shifts. This is particularly important in supporting our trainees so that together we can inspire and create a more resilient workforce.
24 November 2017
Dr Ayman Shenouda
Who’s looking after the doctor?
Federal Health Minister Greg Hunt made a commitment in May to reduce suicide and improve mental health among doctors. This commitment came following the tragic loss of NSW junior doctor Dr Chloe Abbott with Minister Hunt admitting that ‘too often the care is not there for the carers’.
We’re now starting to see some action around this issue. The progress on the mandatory reporting issue for one. It is clear that medical professionals need to seek mental health treatment without fear of retribution. Fixing the mandatory reporting laws is the first key step in supporting doctor health.
A nationally consistent proposal was to be considered this month by COAG Health Council. Minister Hunt has since made assurances following this meeting that work is now being progressed towards a standard by the end of the year. More discussion through COAG will follow to secure agreement but we’re getting closer.
2013 beyondblue study
As in the general population, depression doesn’t discriminate and this was made evidently clear through work led by beyondblue. Beyondblue’s National Mental Health Survey of Doctors and Medical Students revealed for the first time the true extent of the problem. This major study, undertaken in 2013, surveyed more than 12,000 doctors and around 1,900 medical students. 
The stats that emerged from this were alarming. It confirmed high general and specific levels of distress, and high levels of burnout among doctors and medical students. Substantially higher rates of psychological distress and suicide attempts were found than in the general community. Around 10% of doctors reported suicidal ideation in the previous year and one in four reported suicidal thoughts prior to the previous year. 
The study also confirmed that medical students and young or female doctors were most at risk and identified significant levels of stigma towards people with mental health problems. Not surprisingly some experienced bullying and racism as well. 
This is just the start
Despite this major study confirming what we already knew about higher rates of psychological distress among medical students and doctors, there’s still slow policy action around this issue.
At the time, there were calls for urgent action to improve the mental health and save the lives of Australian doctors and medical students. But progress has been slow – very slow. Four years later and we’re still working through one of the key barriers to getting help – which is mandatory reporting.
Minister Hunt is the first federal health minister to acknowledge that mental health issues are tormenting our sector.  Acknowledging the problem is a good start but there is much more to be done. And it’s not all up to government either. We all have a role here and it starts with how we look after each other as doctors. A much broader conversation now needs to occur and it will take all of us to make this happen.
Let’s start with taking our own advice
It’s clear that work-related stressors impact particularly those at the earlier learning or career stage.
We’d all be familiar with the risk factors in the workplace – high-intensity work, long hours, conflicting time demands with a heavy professional responsibility. For some, there is bullying and harassment in the workplace. Broader issues like those stigmatising attitudes which persist despite us coming so far in terms of destigmatising mental health issues in the general community need attention.
The advice we’d offer to our patients around the importance of maintaining work-life balance to counter these issues should also apply to us. The work we’ve all done to destigmatise mental health issues in the community and the shifts achieved here need to be reflected in our own workplaces too.
In achieving a better balance, the answer lies in ‘restoring the pleasure of work – the satisfaction inherent in meaningful work done well’. Working towards ‘addressing the imbalance between excessive demand and perceived low control, and between effort and insufficient extrinsic reward’. This was the advice of Geoffrey J Riley in what remains one of the best pieces written on the subject: ‘Understanding the stresses and strains of being a doctor’ (MJA, 2004). There’s a link as it is a must-read.
Driving toxic culture out
Leadership in terms of dealing with discrimination, bullying and sexual harassment (DBSH) is required.
The extent and impact of workplace bullying and harassment has been exposed in recent years through the press. Reports in 2015 of sexual harassment and ‘toxic culture’ among surgeons led to a public apology to victims from the Royal Australasian College of Surgeons. The apology came after a survey found nearly half of all surgeons had experienced discrimination, bullying or sexual harassment.
A Senate Inquiry into bullying and harassment in the medical profession followed. During hearings in November last year, senators were told of an ingrained culture of harassment and bullying of medical students. There were reports of endemic bullying and underreporting of abuse due to fear of consequence. Gender discrimination and ‘teaching by humiliation’ was also exposed. AMSA evidence stated that up to half of all medical students believing this mistreatment necessary and beneficial for learning.
Positive policy responses include those from the Victorian Government in its work to eliminate bullying and harassment in healthcare. Their strategy focuses on strengthening leadership and accountability; building the capability within the health sector to act and respond appropriately and creating a positive environment that promotes and supports both staff and patient safety.
We need to see more strategies like these. We know that medical students, interns, IMGs and female colleagues have been identified as most at risk. These are issues we need to tackle within our own disciplines and collectively as a medical profession.
We also need more focus on self-care
Self-care has the potential not only to minimise the harm from burnout, compassion fatigue, and moral distress but to promote personal and professional well-being. Developing a self-care plan is important. We all need strategies to mitigate stress and burnout and promote well-being.
More focus on the importance of self-care in the training to develop early those required coping skills is also important. The RACGP in the White Book, Chapter 14, The doctor and the importance of self-care provide comprehensive guidelines encouraging self-reflection, peer support and working as a team within the practice to protect against stress. It provides some practical strategies which are worth pursuing at an individual and practice level.
Responding as a profession
Mentoring is also a key part of remaining resilient as creating (and maintaining) a network of peers is so vitally important. It still is for me. I think we all need to check in with each other regularly. But what more can we do to ensure we are active as a profession to support and mentor our young doctors? Collegiality matters here. Our strength is in our membership and we need to value and nurture our next generation.
It is clear that we need more action on bullying and doctor burnout and mental health issues. I think part of the solution is through formalising a mentoring role in the training system. It provides that safe place to solve problems. But it is currently an add-on for many of us and hard to sustain in terms of an ongoing commitment. It usually comes down to one individual and relies on altruism (alongside so many unfunded parts of our profession). There are formalised scholarship programs but only for a select few. We are relying on a limited pool of mentors which undermines the effectiveness and funding this important role forms part of the solution towards ensuring a more resilient workforce.
The Daily Telegraph. Minister commits funding to address issues crippling young doctors’ mental health. 27 May 2017. Available at: https://www.dailytelegraph.com.au/news/nsw/minister-commits-funding-to-address-issues-crippling-young-doctors-mental-health/news-story/ed7f7871fef2eec8f1d3766b62200854
 AMA. Health COAG progresses approach on mandatory reporting. 13 November 2017. Available at: https://ama.com.au/ausmed/health-coag-progresses-approach-mandatory-reporting
 Beyondblue. National Mental Health Survey of Doctors and Medical Students. October 2013. Available at: https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report---nmhdmss-full-report_web.pdf?sfvrsn=845cb8e9_4
 Beyondblue. Media releases. Urgent action needed to improve the mental health and save the lives of Australian doctors and medical students. 7 October 2013. Available at: https://www.beyondblue.org.au/media/media-releases/media-releases/action-to-improve-the-mental-health-of-australian-doctors-and-medical-students
 Op. cit. The Daily Telegraph.
 ABC News. Culture of bullying, sexual harassment widespread among surgeons, report reveals. 10 September 2015. Available at: http://www.abc.net.au/news/2015-09-10/damning-report-reveals-bullying-harassment-among-surgeons/6763490
 The Sydney Morning Herald. 'Ingrained culture' of harassment and bullying of medical students, inquiry told. 1 November 2016. Available at: http://www.smh.com.au/national/health/ingrained-culture-of-harassment-and-bullying-of-medical-students-inquiry-told-20161101-gsfbuu.html
 State Government of Victoria. Policy Summary. Eliminating bullying and harassment in healthcare. Available at:https://www2.health.vic.gov.au/about/publications/policiesandguidelines/eliminating-bullying-harassment-healthcare
 Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care for others: physicians and their self-care. The journal of supportive oncology. 2013;11(2):75-81.