Caring For Ourselves As We Care for Others: The Psychology of Resilience

Thank you for your warm welcome.

During the past three decades the focus of my research at the University of Minnesota’s School of Public Health has focused on resilience, which I will define as the “ability to bounce back after personal and/or professional defeats”. The central conclusion of this research is that resilience is at the heart of the universe. Indeed it is baked into the DNA of our physical environment.

Some of you may recall the massive storm that went through the Boundary Waters between Canada and Minnesota in 1999. Thousands of trees were uprooted and observers predicted that someday there would be a massive fire due to the dead and decaying wood. Eight years later the prediction came true as lightening ignited a vicious firestorm that raced through 75,000 acres of land destroying 160 cabins. Twenty-four hours later, fire fighters discovered small, slender blades of grass emerging through charred earth. The following spring flowering plants could be seen and in the autumn Jack Pine seedlings could be detected. Today if you were to travel to the Boundary Waters you would see beautiful new pine trees reaching towards the sky.

Not only is resilience baked into the physical universe, it is also baked into the human universe. The movie “Slumdog Millionaire” was based on a novel by Vikas Swarup. The central characters never whine about being orphans, the lack of money or the filth in the slums. “That’s the spirit of India.” Swarup says. “People move on with their lives. Even the slums aren’t places of hopelessness and despair. People are forced to live their lives there because of their temporary circumstances. But that is how they see it, as temporary. Constantly they are trying to get out of the slums. Nobody sits and moans and groans. (The movie) doesn’t show slums as centers of despair and hopelessness. It shows slums as teeming with vibrancy.” Resilience is baked into the heart of the Universe.
Nevertheless, there is reason to believe that our resilient spirit has been diminished.

Surveys suggest that we are not as optimistic about our nation, careers or personal finances as we were a decade ago. Sixty-six percent of the American public believes that the past decade has been one of decline for the United States. Fifty-two percent believe that our children will have it worse off when they grow up, compared to ourselves.

What about resilience in the medical community? The good news is that physicians are remarkably resilient and have a deep affection for the clinical practice of medicine. In a major study on physician morale one doctor said: “Most physicians I know love medicine so much they put up with all the increased aggravation and stress, and still feel blessed that they are practicing medicine.”

There is negative news however: Fifty to seventy-five percent of physicians have experienced burnout, a stress syndrome. Only four out of ten physicians would encourage their children to seek a career in medicine.

Perhaps most sobering is the fact that young physicians are succumbing to work related pressures. According to a study reported in the Journal of The American Medical Association, forty-six percent of internal medicine residents are emotionally exhausted and three in ten show signs of cynicism, lack of empathy or callus feelings on the job. An official of the American Medical Association states the issue succinctly: “Physicians throughout the country have been pushed to the breaking point.”

It is important however, to put these statistics in proper context. Most physicians continue to enjoy the clinical practice of medicine. It’s all the other “stuff” about medicine that drives them crazy, particularly managed care constraints, cost containment initiatives, frivolous malpractice suits and unreasonable expectations of patients.

Now the questions I want to raise are these: How do you stay upbeat when the administrative side of medicine becomes difficult or intolerable? How do you maintain a healthy balance in life when patient demands are excessive?

I want to make four modest, but important suggestions. First, remember these four words: the soul needs playtime. By that I mean that at our deepest psychological level, our soul—our essence—needs downtime.

Hans Seyle, a pioneer in of stress research states that all of us have an “energy well.”

Think of it as a personal fuel tank. We are constantly drawing down the reserves. When we live on fumes, we become irritable and our perception of our future becomes clouded.
How can energy be restored to the fuel tank? The best prescription is exercise because a brisk walk, jog or swim can produce dramatic results: sleep improves, thinking acuity increases and our perception of the severity of our problems tends to recede.

I realize that asking physicians to exercise is akin to asking the Pope not to sin! But when it comes to entering into a disciplined exercise program, it is easier said than done. I recall asking a group of internal medicine specialists, “How many of you advise your patients to exercise?” Every hand in the room went up. I asked, “How many of you are exercising at least three times a week for one hour?” At best, thirty percent of the hands went up.

The benefits of exercise are truly remarkable and what is amazing is that even a little exercise improves both physical and mental health. Several weeks ago, the Lancet, the British Medical Journal reported in a study of 400,000 subjects that only 15 minutes of exercise a day cut the subjects risk of death by 14 percent and extended their life expectancy by three years compared to those who did not exercise.

What does exercise do? It puts new fuel into the energy well and restores our well-being. In our research findings however, exercise alone will not restore the fuel tank to full capacity. What restores energy are meaningful, fun filled, joyous vacations.

Shortly before coming to this meeting I visited with a friend who had just returned from a two week camping vacation. “How are you?” I asked. “I’m full of Poison Ivy. I got bug bites from head to toe. But I am much happier now than when I left for the vacation.”
My idea of a good vacation is not having Poison Ivy or bug bites! But that misses the point: vacations are good for the soul.

The soul needs playtime. Confucius was once asked, “What surprises you about mankind?” Confucius replied, “They lose their health to make money and then lose their money to restore their health. By thinking anxiously about the future, they forget the present… and they live as if they will never die and they die as if they have never lived.”

The second strategy for building resilience is this: Can I get the sand out of my shoes? There is an old Chinese saying: “What makes one tired is not the high mountain far away, but the sand in one’s shoes.” All of us know the experience of getting a small stone in our shoe. We put up with it for a while but finally it has to be removed. Often we marvel about how small the stone is but how much discomfort it instills.

We all have psychological stones that diminish happiness. It could be a marital issue. If your psychological stone relates to marriage issues, be patient. One study followed 100 couples who were on the verge of a divorce but they made a conscious decision to stick it out and see what would happen. A staggering 80% of couples indicated that they were “happy” or “very happy” five years later and glad that they had not made a rash decision to divorce. It seems that most successful marriages don’t solve their problems—they outlast them. Marriages are remarkably resilient if given the chance.

Sometimes the irritant is a child who is not living up to expectations. If you have such a child, permit a word of encouragement. I have seen hundreds of college students who are confused and have no clue about what to do with their life. I follow these students and the vast majority of them find their way in life. It might not be the path you would want for their life, but it is the path they want and need to take. Again, patience is a virtue.
Sometimes the stone is a troublesome colleague who just seems to make life miserable. I know you don’t have difficult colleagues in medicine, but they multiply like hares in academia!

Some of you have worked in academia, I gather from that response!

Let go of the grievances as soon as you can and let them go with humor. On the first day of Senate questioning, Supreme Court nominee Elena Kagan was the object of questions that at times seemed pompous and inappropriate. But the atmosphere changed when Senator Lindsey Graham, R-North Carolina asked the question, “Where were you on Christmas day?” He was referring to that day’s airplane bombing attempt in Detroit. She replied, “Like all Jews, I was probably at a Chinese restaurant”. The room erupted in laughter and some observers suggested that the inquisition was over at that moment.

No matter the severity of the issues you confront, keep your sense of humor in good working order. After President Regan was shot by an assailant, he was wheeled into the operating room and said: “I hope you are all Republicans!” While laying on a gurney he said to the medical team: “I don’t mean to trouble you, but I am still having a hard time breathing.” What grace under duress! The author of the Book of Proverbs had it right, “A merry heart doth good like a medicine, but a broken spirit dries up the bones.”

A third suggestion for building resilience is this: protect the home front. Several years ago I spoke to a group of clergy on stress. After the meeting a minister confided. “I was actually enjoying your speech (How is that for a vote of confidence?) until you reminded us about not neglecting our families. I don’t have any regrets about going into the ministry but I got a ton of regrets for not spending enough time with my family.” I dare say that many of us engaged in busy careers can identify with his observation.

I recognize that “families” take many forms today and not everyone has a spouse and 2.3 children. Nevertheless all of us have “families”—people we love and care about deeply.
How do you keep families resilient? Vacations help. Being present for one meal a day definitely helps. Twenty years ago sixty percent of families had a sit down meal together. Today it is twenty percent. What seems to help most in building resilience in the family is to cut one another some slack recognizing that every person has their own way of coping with life’s challenges.

In the movie “Wall Street,” the lead character went to prison for his financial mischief and after being released made over a billion dollars. His daughter however, would not forgive him for all that he had put the family through. Finally he said: “Honey, we are all human. Give us a little slack.”

Physicians and Academicians share one important commonality: We tend to be perfectionists; indeed we have to be perfectionists. I am a perfectionist when it comes to my research. I pour over the data to make sure I am drawing proper conclusions. You also have to be a perfectionist: One wrong diagnoses or one improper medication can have dire results.

On the home front however, we need to cut a little slack for those we love. Song writer Leonard Cohen once observed: “Ring the bells that can still ring. Forget your perfect offering. There is a crack in everything. That’s how the light gets in.”
Now we come to a final suggestion for building resilience: Keep your focus on what is important. The preservation of your health is one of those main things. Family relationships are another. But a close corollary is to never forget the simple joy of restoring health to your patients’ lives.

I close by telling a story about Manny Villafano who was chronicled in Twin Cities Business magazine. Mr. Villafano is an older person who heads up a company that produces a mesh that is used to bypass blocked arteries in legs. Because of his age people ask him when he’s going to retire and the very notion seems to amuse him. “One guy came to me and said: “Why are you working? Why don’t you play golf or something?” So I said: “Let me tell you a story.”

“One day I was in talking to surgeons about heart transplants. I said: ‘I’ve never seen one. This was Friday.’ The surgeon said, `Okay, we’ll call you this week-end.` I said, ‘How do you know that you are going to a heart transplant this weekend?’ He took me to the window and we looked down at the street which was full of motorcycles. `You see down there? On the week-end there are even more motor cyclists and you’ll notice that none of them wear helmets. We’ll do one.`”

Villafano got a 2:00 A.M. call to come down to the hospital. When he entered the operating room, the patient’s chest was already open. He notes: “The door flings open, and a guy comes in, holding a mask to his face and carrying an igloo cooler. He opens the cooler, and puts the new heart on a table. They start cutting the patient’s heat out and put it on the table too. It’s still beating—every so often, it beats. They put the other heart in the patient and as they are sewing up the chest the new heart starts to beat—I can hear the ‘beep’ on the monitor. And the moment the new heart starts to beat…the old heart stops. It was like life had left the old heart and entered the new. I said to the guy: “When golf is as exciting as that, maybe I’ll take it up.”

True, there are many frustrations in medicine. But the rewards are ample. You are there when people are born, when they meet the challenges of life, and when they die. You are there when the asthmatic child responds to your prescription and can take a breath without effort. You are there when the cancer fighting drugs work and the red and white cells return to normal. You are there when the patient says with relief: “I no longer have pain.”

If there is a better gig in life than that, I don’t know what it might be. Thank you.