We’re confusing resilience with grit [PODCAST]

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“It’s not that physicians need to be more resilient. We’ve failed to provide them with the goodwill to be human and embrace their “whole selves” (people who are resilient often but not always), access to safe and consistent relationships to heal, and systems that support their well-being.

Physicians have persevered despite hardships. They have shown grit. Now, let’s give them supportive spaces, relationships, communities, and systems so that they may have the ingredients to feel resilient more often.”

Amy King is a psychologist.

She shares her story and discusses her KevinMD article, “We’re confusing resilience with grit.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. In the show, we have Amy King. She’s a psychologist, and her KevinMD article is titled “We’re confusing resilience with grit.” Amy, welcome to the show.

Amy King: Thanks for having me.

Kevin Pho: We’ll get into your article in a little bit. First off, share your story and journey to where you are today.

Amy King: Sure. So I’m a licensed psychologist, and I have a private practice where I have worked with kids, families, and adults for over 20-plus years. About nine years ago, I was asked by a group of physicians to join them on a journey around addressing ACEs, the adverse childhood experiences study, which many physicians are aware of. Really, they wanted to take a proactive approach to how we can address trauma in primary care. They knew that I was a trauma-informed therapist and had worked with lots of kids and families and adults over many years.

And so we partnered, and I helped them create a curriculum around not just identifying trauma, which a lot of physicians are being asked to do with ACE surveys, social determinants of health, etc. Really, they felt this pull, ethically: What do we do once we’ve identified the trauma? And so that led us down this path of creating a program where they really could, at every well-child visit and at every encounter with a patient, both talk about trauma in a way that felt a little bit less intimidating and also build resilience interventions that really created those buffering mechanisms that we know mitigate trauma and stress.

And so it was my years of experience as a psychologist, working with people in trauma-informed spaces, that said, “OK, what do we know about development, and when that goes awry, how do we help people get things back on track?” And so I would teach them these little things that we call resilience interventions, and they would try them. Over a period of time, they just began to feel more competent and confident in the way that they were addressing some of the big things that were in the room that they previously felt like they didn’t know how to address.

Kevin Pho: So give us a couple of high-yield tips of what we could do to improve when we want to discuss trauma in the exam room. What are some of these high-yield tips that you could share with us?

Amy King: Yeah, so a couple of things. Just starting the conversation around trauma is one. I think a lot of physicians feel like, “Oh gosh, I’m not a therapist. I don’t know how to talk about this.” But you talk about hard stuff as physicians every day. You break the news about cancer and long-term health concerns and how to manage complex medical conditions, and trauma is no different. It affects the body, it affects the brain, and you’re the only person in the room not talking about it and not aware unless you begin to ask those questions.

And I think once you ask the question, often what you hear from survivors of trauma is, “I feel relieved. I’m so glad to be asked. It didn’t make me feel upset or more traumatized. In fact, it made me feel heard by my physician.” There are a lot of studies that would indicate that people feel healed and heard just being asked about the trauma. So that’s the first thing: Just be OK with asking, “Is there anything that has happened to you in the last six months that’s dramatically changed your life, and is it still affecting you now, and would you like help with that?” Often people just want their physician to know, “This is something really hard that happened to me.” They may not need resources to support them, but they’ll circle back to it, and it really creates this compassionate connection between the physician and the patient.

And the second part is, “What do I do next?” I would say, if I had to pick one thing that is a really high-yield, quick thing to do, it’s to make sure that every single person that you see has a connection. When we look at all the studies around resilience, really, resilience is built in relationship, and that’s whether you’re two months or 20 or 80. We know that connection with another person who sees you and helps you know that you matter really has long-term positive health implications.

Kevin Pho: All right, so let’s talk now about your KevinMD article that you wrote back in August. It’s titled “We’re confusing resilience with grit.” Now, for those of you who get a chance to read that article, just walk my audience through it and share the story of why you decided to write it.

Amy King: Yeah, a lot of us are on social media and different websites, and there were a lot of articles being put out saying that physicians should be more resilient: “We just need to make them more resilient.” And in fact, there were mandatory resilience trainings happening in hospitals, and providers were saying to me, “Oh my gosh, are you kidding me, Amy? I’m being mandated to go and learn how to be more resilient.” And I was like, “Wait a second.”

As an expert in this area, it was really clear to me that physicians don’t have a problem being resilient. There’s no way you make it through many years of medical school, residencies, internships, etc., without having resilience, right? The ability to face and overcome hardships and challenges despite obstacles: That’s the definition of resilience. What people were doing was confusing resilience with grit. And I think really what we’ve been doing is asking physicians to adapt to really unhealthy, oppressive symptoms and systems, and show perseverance despite huge amounts of emotional exhaustion. And so really, they were wanting people to be grittier, when physicians were already showing huge amounts of perseverance despite challenges during COVID, and even pre-COVID burnout.

And so really, what I was saying in this article is, let’s first of all define resilience. Let’s acknowledge that physicians are already resilient, and what’s happened is a failed system for them that doesn’t have the key tenets of resilience, which are relationships over time, and recognizing that resilience is multifaceted, including context and culture. And we’re not resilient every day. There’s no way one person is resilient every day. It happens in fits and bursts, depending on what’s going on.

So I really wanted people to know, first, that physicians need to be acknowledged for already being resilient, and second, that we need to be structuring systems so that they’re more supportive of physicians being in relationships and in healthy systems, so that they could really process a lot of the hardships that they’ve been asked to go through.

Kevin Pho: Now, when you hear a lot of your clients and other physicians talk about these resiliency training courses, what are they like? What have you heard about them?

Amy King: Most of the time, when they’re talking about these forced resilience programs at hospitals, they’re talking about self-care. It’s just like, “We recognize that you’re really on the brink of burnout. You should take better care of yourself.” And there’s really no reflection on organizational ownership of what the organization should be doing to help physicians prevent burnout. And so often it’s, “You can come and meditate for a little bit,” or, “Here’s this somatic squishy thing that you can hold when you’re feeling stressed,” or, “You can go for a walk or take a break.”

And those things are OK for maybe some short-term amelioration, but often when we focus on self-care, what we’re doing is focusing on maybe physical outlets, when really what I think physicians need is keys and antidotes to the emotional exhaustion that they’ve experienced and continue to experience.

Kevin Pho: And from your observations and your perspective as a psychologist, why don’t systems do some of the things that you say? Why do they just shunt a lot of physicians off to these resiliency training courses?

Amy King: It’s a great question. I think a couple of things happen. One, I think large organizations aren’t self-reflective, right? And there’s an individual perspective that is definitely dominant in the medical field: that you should just persevere, you should push through, you should never let them see you sweat. It’s this kind of staunch individualism that is perpetuated in medical school, and later on in residencies, etc., where you shouldn’t tell people that you’re exhausted, that you’re overwhelmed. We don’t encourage physicians to bring their whole selves into the work that they do. So there’s the individual component.

Kevin Pho: And what do you think about that, from your perspective as a psychologist? What do you think about that mindset?

Amy King: It just sets people up for burnout. The number one thing people want to be able to do is be whole humans. And when I talk to physicians, they say, “We’re taught to be boundaryless with our patients and with our career, and yet completely boundaried in who we are, and never share anything about us, and be the consummate professional.” That fracture of self, identifying completely with your job and not with yourself, your culture, the roles that you play in your life, all of the things that give us richness, that compartmentalization will ultimately lead to burnout. And it ends up looking like divorce, addiction, other manifestations of depression and mental health difficulties, or just resenting your job every day.

Kevin Pho: Now, what do you say to those physicians and administrators who say that physicians in fact should be boundaryless, because it was always like this when we were training, and the patient should be a physician’s top priority, even above priorities regarding their own selves? What do you say to people who are stuck in that mindset?

Amy King: I think if people are stuck in that mindset, I’m grateful for the people that are changing it in residency programs. I think there are people of color, there are women, there are people that are speaking up, and people in power saying, “We’re not going to do this anymore.” This system that was created mostly for white men working 80 hours a week is breaking people, and people want to be able to bring their whole selves to work.

And so we see women doing job shares, and people doing locum tenens, and doing things that can fill their cup back up, and even a lot of really good changes in some residency programs around limiting hours and making sure that residents are getting sleep. And I know a lot of old-school thought is like, “Oh, they’re getting soft.” No, they’re actually recognizing that these are human beings, not robots, and human beings are what will transform medicine. And when I see people able to take care of their whole selves, that’s really how things begin to shift, even in one-to-one encounters.

Kevin Pho: So we talk about burnout a lot on KevinMD and on this podcast, and I think that what you say has a lot of resonance, that we do need to change the systems. There are a lot of physicians who are trapped in the systems that you describe, and they want to break out, and they want to make some changes. Now, when they work in a system that continues to have that previous mindset, what are some ways that they can push back? What are some ways that they could function in a system that just tells them to go to resiliency training without that self-reflection that you talked about? How can physicians function?

Amy King: First of all, there are lots of other things that physicians can do, right? If they’re in a system that they really don’t like, one of the first things is just coaching them and saying, “Is this the best fit for you? Is this the best fit for your family? Is this the best fit for your mental health?” And a lot of times physicians go into the work they’re doing like, “This is the one way I can do this.” But there are lots of ways to practice medicine, and I do a lot of coaching around that.

But within that, even if they’re saying, “No, I really am here. I’m committed to this hospital. I really want to work with this group of people,” what I would say is we have to then begin to be clear about priorities and expectations. And so sometimes we’ll do a boundaries exercise. The idea of boundaries doesn’t mean, “OK, I’m going to just quit my job and tell them I’m not going to do this.” Boundaries mean, “I want to be in a relationship with you, even if the ‘you’ is an organization, and so I need to define for you what’s OK and what’s not OK for me.”

And so I help physicians develop scripts about how to do that and weigh the pros and cons, so they can really practice that, because it is not something that’s encouraged. As I was saying, physicians are taught to be boundaryless, so now all of a sudden they’re having to unlearn that, even asking for small things like not being double-booked right before their lunch hour, so that they could do some charting, or so that they could actually go and get a walk or take a break. Those things previously felt like, “Oh my gosh, that’s insurmountable. I can’t ask for that.” It’s like, we can begin to make just small little changes that might really help you feel like you’re getting your cup filled back up.

Kevin Pho: So I think that concept of pushing back on boundaries is tremendously important, because a lot of physicians, to get where they are, you’re right, they have to be boundaryless. They have to say yes to everything, or else they wouldn’t get to where they are. So what are some quick tips? What are some quick words that physicians could say to just start gently pushing back?

Amy King: “I want to be in a relationship with you.” Maybe that’s the clinic, maybe that’s the practice owner, whoever the “you” is defined as. “I want to be here, and I want to serve my patients.” Start with that. Start with what you want to do, and then say, “In order to do that, I need,” and maybe just put out two or three bullet points, right? “I need to not be double-booked. I need my last patient encounter to not have high complexity,” whatever the case may be, right? It might be little things. “I need to not get alerts and calls when I’m on my days off, and not be asked to come in and cover call when I’m on my days off.”

Really, what you can do is ask, if I could change three things right now that would make me just go, “Oh, that feels so much better,” let’s advocate for those first. “Here are the three things I need.” And then again, sandwiching at the end: “This is so I can continue to take care of patients, help them thrive, and live their best life, but also make sure that I don’t enter a space where I don’t want to be in this profession anymore.” So just start with “This is where I want to be, these are the things that I need, and I’m asking this because I want to continue to be in this profession for 20, 30 years, and not be burned out two years post-residency.”

Kevin Pho: Now, could you tell us a case study or a story where you’ve coached someone to do that, and that’s actually moved the needle in their situation?

Amy King: Yeah, I was talking with a pediatrician the other day, and he was trying to figure out how to set limits. All of a sudden, the patient portals, I don’t know about all your listeners, but it was just like this 5,000-word essay. So I said to him, “OK, what would that be like if you just went back and talked to your team partner that you share call with, but also your MA, and said, ‘What feels reasonable to us in a given day? What can we respond to, and then how are we going to cut that off?'”

And at first, everybody was like, “Oh my gosh, are you kidding me? Then we’re not taking care of our patients.” You are taking care of your patients, because you’re helping them to define what’s OK to put in here for information, and when they need to actually come in and see their physician. There’s only so much triage the MA was able to do for him, and they were both exhausted. And so they limited it. They actually went into the EHR, and they were able to change it. You can do things like that, where it limits the words to a certain amount. And he and the MA decided, at this point, here are some criteria where you need to just call that person back and say, “You need to schedule an appointment.” And everybody felt so much better. It was like, “We can do that. We can put a boundary on a patient.”

The other thing that I think of as a quick story is putting boundaries on how patients treat the providers and the staff. So I’ve coached many people through calling out what I would call workplace incivilities, where I recognize that people are stressed, and they come in and take that out on your front office staff, or the first people that greet them. Often, by the time they get back to the physician, they’re super nice, because that’s their doctor. But setting boundaries on how patients can talk to your staff has also been really impactful in terms of the team approach and taking care of your team.

And we talk through a lot of scripts about just saying to the patient, “I absolutely see that you’re frazzled, or that you’re running late. We’re going to make sure that we see you. It’s not OK to talk to my front office staff like that. She’s working really hard to meet your needs too,” right? And again, you’re setting a boundary: This is what’s OK, and this is what’s not OK. “I want to see you. I want to be the best physician for you, and you may not talk to my staff like that.”

Kevin Pho: We’re talking to Amy King. She’s a psychologist, and her KevinMD article is titled “We’re confusing resilience with grit.” Amy, what are some of the take-home messages that you want to leave with the KevinMD audience?

Amy King: Yeah, I’d say the biggest thing, and my passion, is that I want physicians to know that they can address trauma. They can address their own, by setting boundaries and decreasing burnout, and they can also feel really competent and confident working with their patients to address trauma and adversity. There’s a lot of support out there, so that they can feel more competent in doing that. And if they just start with one thing, it’s about making sure that they are connected to a community as a physician, for themselves, and that when they see patients in crisis, that person gets connected to just one other soul.

Kevin Pho: Amy, thank you so much for sharing your time and insight, and thanks again for being on the show.

Amy King: Thanks so much.

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