Doctors under pressure need resilience, not mental toughness

Following heated debates in the medical press and social media about the value of resilience training for medical students and doctors, this blog and the GMC’s #gooddoctor event in Newcastle on 16th July on the theme of resilience, provide an opportunity to put the record straight.

I am a Consultant Liaison Psychiatrist and Clinical Director of the not for profit social enterprise ‘Connecting with People’. Connecting with People has pioneered a strategic, evidenced based approach to suicide prevention, emotional wellbeing and mental health awareness, combining compassion and governance

We contributed to Sarndrah Horsfall’s external review of doctors who die by suicide whilst under GMC investigation. We suggested that medical students and doctors would benefit from emotional resilience training and that staff with line manager responsibility would benefit from mental health awareness training. We also suggested that everyone should know how to respond compassionately to others in distress and how to respond safely to people at risk of suicide.

Connecting with People

“Seeking help is not a sign of weakness. It may be one of the bravest things a doctor ever does, and may even save his or her life.”

Strategically increasing wellbeing and resilience

Wellbeing, as defined by the World Health Organisation, is when someone ‘realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’. Medicine can be a stressful job and more than ever we need to ensure we have emotional wellbeing, resilience and resourcefulness. Importantly emotional wellbeing is not about ‘mental toughness’.

Emotional resilience is about adaptive coping skills, understanding and managing one’s emotions and seeking social support to enable the ability to ‘bounce back’ or even experience post-adversity growth following a stressful event. It is not only the ability to cope with stress but being able to thrive and flourish even in difficult circumstances. It is not about asking doctors to ‘grin and bear it’ and to handle intolerable organisational pressures or excessive workloads. Neither is it about the naming and shaming of ‘weak’ doctors for not being tough enough to cope with the pressures placed upon them. Quite the opposite, in fact.

People may not consciously realise that they can strategically increase their wellbeing and resilience. Sarndrah Horsfall’s recommendation that medical students should have resilience training followed her hearing about the training developed and delivered by Connecting with People. Several other organisations also deliver such training. This kind of training enhances emotional literacy, debunks myths associated with emotional problems, reduces the stigma and fear of talking about emotional distress, suicidal thoughts, self-harm and barriers to seeking help. It also promotes early intervention, the value of connectedness, of relationships, of self-care and of seeking support if needed. Seeking help is not a sign of weakness. It may be one of the bravest things a doctor ever does, and may even save his or her life.

Compassion starts with self compassion

Being a good doctor requires many qualities: compassion, knowledge, skills, perseverance, team skills, flexibility and willingness to learn. But perhaps the most important of these is compassion. And compassion towards others must start with self compassion. If we don’t look after ourselves, we may find it challenging to deliver effective care, be more vulnerable to burn out or a potential catastrophic responses if we experience a ‘failure’.

Emerging evidence suggests that improving a person’s mental wellbeing can reduce morbidity and mortality. Stress and mental health issues are the most common causes of sick leave [PDF] (to be off work) in high-pressure workplaces. Together they are the second biggest occupational health problem in the UK [PDF] after musculoskeletal problems. People can learn how to increase their resilience by adopting certain mindsets, behaviours, emotional regulation strategies, coping styles and by adopting helpful self-nourishing daily habits. Once people understand that they can build and maintain their emotional wellbeing and resilience, they can then commit to a personal plan of how they will do so, which ideally includes how to access further support if they ever need it.

Professional athletes know that pushing themselves at 100% of their capacity 100% of the time results in little or no long-term performance gain and will probably shorten their career. So they build ‘recharge time’ into their training routines. We could all benefit from the same approach when developing and maintaining emotional wellbeing and resilience. All doctors need a compassionate level of suicide awareness, a personal strategy of how to maintain their wellbeing and how to safely self-manage acute distress by having a ‘ready-made’ safety plan to fall back on should they ever become suicidal. They also need to work in nurturing environments that support and engage them, validate the particular stresses of their work, respect their capabilities and make provision for the need for reflection and self-care strategies.

I welcome contributing to the GMC event on resilient doctors and look forward to discussing practical and pragmatic things we can do to make doctors genuinely more resilient, not just toughen them up.

Find out more about the 2015 events, and register your interest in a place here. Information on 2016 events will be published shortly.


Dr Alys Cole-King (@AlysColeKing) is a Consultant Liaison Psychiatrist (Betsi Cadwaladr University Health Board) and Director ‘Connecting with People’ – a social enterprise. Alys is a member of the Royal College of Psychiatrists Patient Safety Group and has contributed to College Reports. Alys sits on the Royal College of General Practioners (RCGP) Mental Health Training Group, and has contributed to RCGP and RCPsych curricula and the All Party Parliamentary Group for Suicide and Self-harm Prevention.

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17 responses to “Doctors under pressure need resilience, not mental toughness

  1. Pingback: Doctors under pressure need resilience, not mental toughness - Free for all - Blog - Free for all - BMA Communities·

  2. A timely and helpful contribution, thanks!

    Two points:

    1. With earlier accession to the GMC specialist register since MMC/Calman, and later retirement ages, the cumulative pressure on consultants (& GPs) over a career makes emotional intelligence & strategic career management the more critical. Neither individuals nor the NHS have been great at this in my experience over the years.

    2. Why not include a burnout screening tool (e.g. ProQOL or some such) as part of the appraisal / revalidation cycle? We screen for physical illness, here’s a problem forwhich


  3. Reblogged this on #healthystaff4healthypatients and commented:
    The GMC’s #gooddoctor event is happening in Newcastle today – This blog post has so many powerful messages for creating healthy doctors. I am happy to see the GMC take this cause in a positive direction today, and to see that resilience is not necessarily about being mentally ‘tough’…Re-blogging this in support of the cause 🙂

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  5. Doctors are sympathetic and empathetic beings, we are trained to be humanitarians. The human being does not work that way – in holistic medicine we see that when the emotional body opens up through training, that the individual also becomes more vulnerable to emotional assaults that happen in an environment that may be prone of swift libel and slander (‘bullying’) and in individual relationships with patients (‘defamation’). When that happens, when doctors are falsely alleged and emotionally/mentally hurting, my advice is to stick to the scientific method: gather all the evidence. Until the time comes for you to strike back – by directing your complaints at the right stations. This is time-consuming in this world that expects first the victim to proof its innocence. Or evade this culture if hurting gets too much. There simply are other pools where there is ‘to be dealt with innocent until charged’. We all have the entitlement for good mental health and well-being. ‘The pursuit to happiness’ is down to us. :-))

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  7. I’d like a link to the evidence for the alleged effectiveness of this training please.

  8. Yet again, another medical body, the GMC, sidesteps dealing with the reality of the current crisis in the NHS (intolerable workload, understaffing, underfunding…..etc) and suggests we become more resilient, with no evidence to support it as a strategy.

  9. I think it’s also a lot to do with university experience at medical school, were the lecturers and more importantly the educational supervisors or mentors supportive, were there a variety of things to do and ways to express yourself as a student. In my experience, a fellow student and housemate had a parasuicide over a finished relationship in my 4th year, I helped her to A&E and the only support I got was a phone call a couple of days after asking if I was alright. That night has stayed with me till this present day, has shaped my perception on the profession and whether I really wanted to stay in it. As doctors and medical students we do our utmost to help but we are stigmatised for being off sick and causing ‘problems’ with staffing. I took myself out of that environment and left medicine altogether. With greater sight and wisdom, I hope to enter medicine once again but with more caution and self awareness of how the staffing levels are run and when to say no to extra workload from nurses and SHOs. I burnt out just to help out and found myself being walked over. So self compassion definitely but also a more realistic portrayal of the dangers of being a naive HO please!

    • Thanks for sharing your thoughts. I believe that education on maintaining emotional and mental wellbeing should be part of medical school curricula. Whilst there are sources of advice and support at universities, the approach is very much reactive and not preventative.

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