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Join Frances Mei Hardin, an otolaryngologist, as we delve into the world of distress tolerance in medical residency training. Discover practical techniques, real-life anecdotes, and evidence-based practices to help residents navigate the intense and challenging environment of medical training. Learn how distress tolerance skills, including radical acceptance and TIPP techniques, can be valuable tools for maintaining well-being and enhancing patient care.

Frances Mei Hardin is an otolaryngologist.

She discusses the KevinMD article, “Skills for resident physicians to increase distress tolerance.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Frances Mei Hardin. She’s an otolaryngologist, and today’s KevinMD article is titled “Skills for resident physicians to increase distress tolerance.” Frances, welcome to the show.

Frances Mei Hardin: Thank you so much for having me, really a pleasure to be here.

Kevin Pho: So let’s just start by briefly sharing your story and journey to where you are today.

Frances Mei Hardin: Absolutely. So I was a biochemistry major at the University of Notre Dame. I went on to complete my medical school training at Case Western, and then I underwent an ENT residency training program. I’m currently in my second year of practice as an otolaryngologist in Tennessee.

And what really spurred a lot of my work postgraduate has been the fact that my residency training experience was at a malignant program. So very early on I started to search for resources on resident mental health and wellness, finding very little specific to residents and their unique challenges online. Many hospital wellness measures that I found at the time were aimed more at attending physicians and various retention measures, rather than, again, this unique set of problems that often resident physicians can face in their programs.

So what happened was, by the time I was a chief resident I joined a DBT skills group. Finally as a chief, or a fifth year ENT, I had some freedom over my own call schedule and things like that, so I said, OK, let’s do it. 7 p.m. on Tuesday evenings, I give myself permission and a little bit of protected time to go to DBT skills group. And DBT stands for dialectical behavioral therapy.

What I learned there was a completely new skill set that would have just been enormously helpful in all of the preceding years, not even really just PGY-1 through five of residency, but honestly wonderful tools that even are useful to medical students, especially as they’re at the M3, M4 level and working in the hospital.

So I created the brand Rethinking Residency to provide an outlet, a community, a set of static resources that are available to resident physicians, and of course med students, fellows, recent grads, et cetera.

Kevin Pho: All right, so you talk more about that in your KevinMD article, of course, “Skills for resident physicians to increase distress tolerance.” So take us into one of those sessions. What are some of these revelations that you wish you had known early on in your training?

Frances Mei Hardin: Yes, absolutely. So just to do a real quick bird’s eye view of DBT. So dialectical behavioral therapy, again, it’s something that would not be uncommon for us to have heard of, touched upon in medical school, but certainly as a surgical subspecialist it’s not something that’s really revisited. I don’t have a strong psych background post-medical school or anything like that.

So being introduced to DBT, it has four pillars. Those are mindfulness skills, interpersonal effectiveness skills, distress tolerance skills, and emotional regulation skills. Just right off the bat, hearing those four buckets, at the time it was a revelation, because I thought, those are great, I would love to turn it up to 100 in all four of those categories.

And again, one thing that I had found myself vocalizing, specifically looking for for many years, were things to increase my distress tolerance, because ultimately in a malignant surgical training program there were many situations associated with a fairly high level of distress routinely in the workplace.

So the distress tolerance skills are particularly useful, in my opinion, to the resident physician who are constantly faced with those high stress situations that can involve everything ranging from being pimped in front of a big group on morning rounds to being screamed at in the operating room while you’re scrubbed in.

And so as a surgical resident, when you’re Googling wellness tips and you’re trying to find coping mechanisms, a lot of the stuff out there is just not practical for a resident, because the top hits you’ll see are, take a lap around the block, go get some fresh air. Another common one people will hit you with, listen to your favorite song. Also super impractical for a scrubbed in person, or somebody of course on rounds, things like that, or even in a high acuity situation in the ICU. Like, all these types of situations, we need to have more ingrained skills.

And that’s where it really turns toward a lot of this inner work, as opposed to outer environmental changes. As a resident physician you don’t have a huge amount of control over your environment. I really love the famous stoic quote that says, when we can no longer change our situation, we are forced to change ourselves. So that’s kind of the driving force and the framework for this.

What I focused specifically on for my KevinMD article was the distress tolerance bucket and those sets of skills. One excellent example of that, really easy, very quick to learn, I have often utilized this myself, is taking a page from the Navy SEALs and doing the box breathing method. So that’s where you inhale for four seconds, pause at the top for four seconds, exhale for four seconds, and then hold down there for four seconds before starting your next inhale.

What is unique about this breathing pattern, and people may have heard of other patterns such as 5-6-8, there’s a variety in meditative practices, but the Navy SEALs 4-4-4-4 box breathing is a non-physiologic pattern of breathing that really does require this extra level of concentration, and it can help reset the vagal nervous system. So that’s one that’s very easy to do. Again, if you’re feeling activated in a conference room setting, say in a grand rounds or something like that, residents can use that breathing technique. It can also of course be done scrubbed in.

Another example is self soothing by grounding in the senses. Of course I always have to say the caveat, if one is actively working as the first assist it would be really difficult to do something like this practice, because it does require a little bit of attention and concentration. Things like focusing on your breathing, I think feasibly could be done by an experienced first assist, things like that. But often some of the people who need the most regulation and reset, like in an operating room setting, would be even medical students or more junior residents, because at that level you’re just retracting and you might be the bystander to some fairly nasty interactions or a high stress situation.

So self soothing by grounding in the senses is where you ground yourself mentally using all five senses. The common form of this meditation involves naming five things that you can see, four things that you can hear, including for instance, I can hear the Bovie going off, I can hear the anesthesia machine, things like that. Three things that you can touch, which can include, I feel my feet inside their shoes on the ground, I feel my hand on this retractor. Two things that you can smell, Bovie smoke, things like that. And then one thing that you can taste. So that, in addition to many of these meditative practices, can really be used to keep somebody more psychologically protected in a high stress situation.

Kevin Pho: Now, before talking more about these techniques, for those who aren’t familiar with surgical training, what exactly is it like to be in an operating room, people yelling at you, or being pimped in front of dozens of people? Just take us into that scenario, for people who just aren’t familiar with the training, what’s that like?

Frances Mei Hardin: Totally. Well, everybody’s experience is different. I will say that as a medical student, getting pimped on rounds as an M3 and M4, I really relished it. I felt like the training environment was still supportive, and typically if a medical student or myself got anything incorrect it was not met with derision or ridicule. So I have this interesting history where pimping never used to bother me.

Again, in a more sustained malignant training environment, what it feels like is just that you show up to your job every day, the operating room, previously called the operating theater, it really does feel that way. So you’re in a public environment, you’re scrubbed in, you cannot move more than kind of six inches in any direction, your hands can’t leave the sterile box, and somebody can be within two feet in front of your face, really screaming directly into your face, and they can say whatever they want to you.

And what’s really difficult about that situation is, one, having no recourse for kind of the bullying, the intimidation, directly to your face. But two, there is a public humiliation element of it that’s very real, it’s very pervasive, it’s hard to forget that there’s tons of people in the room. And not only that, but that also kind of adds this layer of pain, I think, to the whole experience, when everybody is an active bystander and they kind of look the other way.

So these types of patterns, I think that if it happens occasionally in someone’s experience or in their training, all physicians are really resilient, I think people really deal with it well and get over it. But in a five-year surgical training program, if there’s something like this sustained pattern, then I think that that can really get at you, and that can eat at you a little bit.

So I got to that place, that’s why I started to really seriously look for all of these resources. A lot of people’s advice is just keep your head down and run the clock out. And while that’s what I did, I did it successfully, I’m in my second year of practice now, what I would like to take the next step to ask is, what if we didn’t just survive but we thrived? And I want to remind everyone that there is a life after training. So if you just squash it all down and you just think, OK, this trauma, this will just evaporate when I graduate and go on to my new attending life or my new fellow life, I can assure you it does not just evaporate or dissipate. Mine certainly did not.

Kevin Pho: Now, what does it say about the training culture that we do need to teach ourselves some of these techniques rather than changing the culture itself? So comment on that tension, and why is it so difficult to change that culture?

Frances Mei Hardin: Totally. Well, the system has been around a lot longer than we have been, certainly than I have been. What I love, and to use a spin zone, because I definitely appreciate what you’re talking about, I have no ability to control or change other people, right? And certainly these attendings who are in their 50s and 60s and beyond, I don’t want to be Sisyphus, working with those people and trying to change their minds.

But what I will say is, because we have the ability to change ourselves, we can do that. And not only that, but we can change other people’s experiences. And so I will say my junior residents still contact me to this day, they’re now senior residents, and there is a very different culture, there’s a very different way that they teach their junior residents. Their junior resident experience was very different from my own, because I was able to just say, I know exactly what I don’t want to be like.

That being said, learning these skills for ourselves is what makes it possible to kind of break that cycle. The biosocial theory of behavior just says and explains why we kind of model how we were trained.

Kevin Pho: So give us a story or an example, and it could be a hypothetical case, where someone used these techniques in a distress setting and it moved the needle for them in a positive direction. Just give us a practical example of how this would look.

Frances Mei Hardin: Totally. Well, so one that comes to mind, and this is a very positive example, I think it really shows, one, that this is not magical, it doesn’t work overnight, these are truly learned skills that need to be practiced and implemented in a very real way. But three, it really shows kind of rewards for trying.

So when I was a chief resident, one of my co-residents and I, we were starting to learn about and really try to implement these techniques. So we were sitting in a departmental meeting, the nature of the meeting was sensitive and unpleasant, we were actually missing an entire class of residents in my program at the time. So, fairly high stress meeting. And my co-resident and I texted each other under the table, both getting very activated, because again, we’re PGY-5 by this point, not our first rodeo, we were both activated.

And I texted her and I was like, OK, trying the box breathing. And she texted me, she’s like, I’m trying it, it’s not really helping. But we’re texting back and forth, and just the levity that that brought, because we both were like, I’m doing it, I’m doing it, and you’re really trying to do it. But that in itself, the act of not just choosing to get activated, stay miserable, but really putting a good faith effort into a positive, productive coping mechanism, that really showed me that day that we were moving in the right direction.

Kevin Pho: We’re talking to Frances Mei Hardin. She’s an otolaryngologist, and today’s KevinMD article is titled “Skills for resident physicians to increase distress tolerance.” Frances, let’s end with some of your take-home messages that you would like to leave with the KevinMD audience.

Frances Mei Hardin: So my take-home is really that these skills work. They take practice, like any other skill set that all of us are working on acquiring. And many people feel trapped in their residency training, in their job, even maybe even at school. And so just a reminder that when you can’t change the situation that you’re in, then you can still change yourself.

Kevin Pho: Frances, thank you so much for sharing your perspective and insight, and thanks for coming on the show.

Frances Mei Hardin: Thank you.