Get tough: Cultivating clinical resiliency

Early in training, it’s all about the clinical building blocks: diseases, therapies, workflows. As one matures, however, the hallmarks of personal growth become more subtle.

One of the hardest to pin down is what we’ll call toughness. In another age and place, this meant something like the following: if we dropped you alone in the jungle, with only your wits and a buck knife, would you survive?

Adapted for the modern ICU, it looks different: if we left you alone in the unit with no backup, three admissions looming, the phone ringing off the hook, and two patients coding simultaneously, would you handle it . . . or would you spiral?

In audio recording, there is a phenomenon called clipping. Clipping occurs when the audio level exceeds the safe maximum for the hardware and becomes distorted, creating a permanent blemish in the track. To avoid this, audio engineers strive to maintain their inputs (individually and in summation) well beneath this limit, allowing plenty of “headroom” in case of unexpected peaks.

Functioning as a clinician works in much the same way. Things may be calm, or they may be bonkers, but the most important thing is to keep the overall flow from becoming “too much”: an invisible threshold, found at different points for different people, beyond which their output qualitatively, uncontrollably hits a wall and begins to unravel.

You really don’t want to reach that point. Bad things happen there. Blatant medical errors, either of omission (neglect) or commission (mistakes). Lashing out at others and damaging professional relationships, or taking that stress home and damaging personal ones. Or in the worst case, simply breaking down—burying your head in your hands and refusing to answer the phone.

The responsibilities placed upon you are like incoming fire, and you are a ship under attack. Taking damage is inevitable, but the difference between a damaged ship that can still sail and a ship that sinks is found in its durability. What are the traits that make one clinician bulletproof, another more fragile?

There is experience and skill, of course. If a situation is fairly novel and requires contemplation and second-guessing, it’ll require more bandwidth, time, and mental effort to navigate. With time, more and more situations become routine. Competence is the tide that lifts all ships.

There is probably also some ineluctable element of personality; certain people may be fundamentally more resilient. If so, that can’t be trained.

Yet some relevant skills can be trained, and cultivating these may help journeymen clinicians evolve into tough, efficient, independent practitioners who can sail any sea without capsizing.

Here are three of those traits.

Stress inoculation

To a certain extent, stress tolerance is a learned skill. Your set point is determined by your habitual environment. If you’re accustomed to functioning at a 4, you’ll experience shock when things peak to a 7; if 7 is all you’ve ever known, you won’t blink an eye.

Critically, this doesn’t mean the former person can’t handle a 7—but they may think they can’t.

I was an early adopter in the first years of the CrossFit fitness program. CrossFit was based around short workouts of extraordinary intensity, the sort of punishing bursts that left you gasping and semi-unconscious by the end. Physical adaptations notwithstanding, one of the lessons you learned from this nonsense was simply how to suffer. The first time you tried a CF workout, you’d notice the sensations in your body, assume they meant you were dying, and slow down. The tenth time, you’d feel the same, but you’d realize you weren’t about to die. You were in pain, but not in danger, and you could keep pushing if you had the grit. It was unpleasant, but nothing more. Learning the difference between what’s difficult and what’s impossible can only occur by spending time in the space between.

Even if you stopped the training and lost your physical skills—as I did—the mental lesson tended to stay with you. You still knew, or your muscles knew, what it was like to exert yourself at 100%, and that meant you could do it again if you needed. Your true limits were still your limits, but you could walk right up to them and peer over the edge while others stopped much further back, restrained by psychological guardrails.

The same applies to our clinical responsibilities. Someone who trained in a scrappy inner city hospital, with a census always at 110% capacity and patients routinely stuffed into hallways and ceiling boards, is not going to blink when things get a little nutty. Their counterpart from a plush environment where they’ve never felt pain may be another matter.

It’s important not to overemphasize this trait, because it can have toxic ramifications. There is learning in suffering, but only to a degree. At a certain point, suffering is just suffering. Serious and legitimate questions have been asked about some of the burdens heaped upon resident physicians during their training, often justified as “cultivating toughness.” Okay, sure. But how much do they have to hurt to learn that lesson?

(It brings to mind an old argument in ethics, which sounds like this: When asked why a good God would create a world filled with evil, the interlocutor explains that evil is needed to provide contrast, and that good would be meaningless without its opposite. In response, one waves their hand at centuries of starvation, genocide, and horror, and asks—yes, but did we need quite so much of it?)

Like most stimuli, there is a therapeutic range. Be cautious of those with an agenda handing you lemons and calling them personal growth.

Efficiency and flexibility

Efficiency is how much time it takes to do your job, and it’s clear that greater efficiency allows a greater workload tolerance. This is a skill to develop before it’s needed. If you’re barely efficient enough to keep pace during an average day, that’s a sign that you’ll struggle when things get rough.

Instead, prospectively and in the light of day, optimize your processes. Do it with a scalpel and magnifying glass and exacting ruthlessness. Obvious inefficiencies are easy to find, but merely imperfect ones require conscious reflection to recognize. If there’s any aspect of your workflow that routinely seems to “take forever,” disassemble and rebuild it until it’s a doddle.

The other side of this coin is flexibility, triage, and prioritization. We all have a standard approach to things, but the resilient clinician knows that this default can be customized. Forcing yourself to use your regular approach when under duress isn’t always necessary, and is the hallmark of the kind of folks who routinely stay at work two hours past their shift. (See How to be whelmed for more on this skill.)

A great example of both efficiency and flexibility is documentation, often one of the biggest time burdens in medicine. To be efficient, make the investment in your templates, macros, and shortcuts so that note-writing can be as fast as possible, with no wasted movements. To be flexible, understand that a note might be discursive and thoughtful on a quiet day, but can also be short and terse on a busy one. The latter may lack some of the detail and formatting of the former, but it’s not going to kill anybody. I myself have a standard note template, a “short” template for simpler situations, and even a “supershort” version containing only the essentials. If your mind can’t tolerate the idea of shortening a note because you’re busy, that inflexibility may make you a careful craftsperson, but it also means you won’t be able to offer as much patient care. Because, well, you’re busy writing your note.

In our analogy of the battleship, flexibility is the ability to perform damage control. As you take on water, by shutting hatches, sealing bulkheads, and jettisoning unnecessary cargo, you can limit and direct the damage so your most important functions remain intact.

The undesirable extreme of flexibility, of course, is mere laziness—pushing the limits of how little you can do while still drawing a paycheck. The goal isn’t to reduce your overall output of medical care, it’s to thoughtfully allot the finite portion you have.

Understanding your weaknesses

The final key to taking fire without catastrophic error is knowing your own vulnerabilities.

When push comes to shove, your failure points aren’t going to be where you’re strong. They’ll be the little weak points that exist already, that you gloss over and compensate for in ordinary circumstances, that are “not really your thing” or are even a charming personality quirk. Those holes in the Swiss Cheese are a preview for where you’ll fail under stress.

Ignoring them means they will surprise you. Knowing and acknowledging them means you can expect trouble and watch out for it.

Do you become unpleasant and short-tempered under stress? Monitor your tone and ensure you’re not snapping at colleagues. Do you tend to rush at critical moments during procedures, introducing errors? Consciously slow down at the key steps. Are you absent-minded at baseline, and tend to forget things as the pace picks up? Use additional care to make checklists, frequently pause and search for what you’ve missed, and ask others to double-check you.

Conclusions

There are plenty of smart, kind, wonderful clinicians who are nevertheless not the sort you’d want sitting in the driver’s seat when the stuff hits the fan. In some cases, that’s just how it is; not everyone is good at everything, and they may have other skills to offer, such as hyper-focusing on specific tasks at which they excel.

To practice critical care with a degree of independence, however, requires at least a modest capacity to calmly navigate chaos. If you’re not there yet, cultivate it today. Tomorrow may be the day the storm arrives.

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