Physician, anneal thyself

Stress appears an inescapable part of the practice of healthcare, but is a focus on building resilience the best way to approach the problem?

I’m not really a sporty person, but I like running and cycling and open-water swimming—keeping fit, keeping healthy, mostly just enjoying the glorious countryside where I’m blessed to live. Earlier this year, I was given a sports watch: it measures my heart rate, tracks my routes, and even tells me the time. I love it.

The watch indicates how hard I’m exercising (stress), but also how much I’m being stretched (strain) and compares this with a longer term indicator of my coping ability (tolerance). A clear display shows me, and anyone else who cares to look, where I am on my journey.

I wish there was a watch to measure the stress, monitor the strain, make manifest the tolerance of those working in healthcare: a wearable-tech portrait of nurses’ and doctors’ mental health and wellbeing.

Stress appears to be endemic in healthcare; the causes are legion and a degree of stress is, perhaps, an inescapable part of what it means to be a doctor or a nurse. It’s difficult to say whether stress has risen, or whether we are becoming more attuned to its toll at the human level, to the strain. Studies show high rates of burn-out, of compassionate people unable to continue in their roles, of caring individuals unable to carry on with their lives.

My friends walked on – I stood there trembling with anxiety and I felt a great, infinite scream through nature.

Edvard Munch

Edvard Munch created perhaps the best known pictorial representations of inner distress. Walking with two companions by the side of a fiord in Oslo he was overcome by his surroundings:

He spent years trying to portray the turmoil he experienced: first, in Despair; later, in the various versions of The Scream. A recent exhibition at the British Museum showed that his response didn’t spring from nowhere; his previous paintings clearly depict an ongoing, inner struggle—with childhood loss, with repeated rejection—with little left for life’s slings and arrows.

 

 

It is counterproductive to ask physicians to “heal themselves” through superhuman levels of resilience even as the practice environment continues to deteriorate.

Bryan Bohman and others

Many well-meaning initiatives have tried to build resilience in healthcare staff, to help them cope with the stresses they experience. The term started to be applied in the 1970s, but the concept dates back much further, underpinning, for example, the efforts of the combatant armies in the First World War to find ways to return psychologically damaged soliders to the trenches. The concept of patching up wounded individuals and sending them back to face the guns amid worsening conditions, whatever the cost—and with no sign of progress towards an armistice—remains a common perception of resilience amongst those on the frontline of healthcare.

Perhaps, we can better understand the limitations, and the antagonism, by examining the underlying model and metaphor.

Resilience is a term borrowed from materials science—a measure of how much stress (force) can be absorbed for a given level of strain (stretch). A steel girder supporting a bridge will lengthen with increasing traffic. Within working limits, the girder will stretch in proportion to the number of cars.  When they leave the bridge it will spring back to its original dimensions and properties. A resilient girder will stretch less for the same weight of traffic.

But increase the vehicles on the bridge beyond healthy limits and the girders will experience permanent, non-elastic deformation. Passively reducing stress is no longer enough: in order for the girder to regain its shape, it needs an active process of remodelling. Continue to drive HGVs onto the carriageway and eventually the girder will fail.

It might seem that the answer is to increase resilience, so that the girder can cope with more stress. Quenching is the process of heating then rapidly cooling metals, to increase their resilience. The resulting girder will certainly be very hard, and there will be little in the way of external signs of strain as the stress load increases; but it will also be extremely brittle, and will fail catastrophically, and without warning, as it reaches its limit.

For girders, better by far to increase toughness—which combines the elastic and non-elastic portions of the stress-strain curve— by annealing: careful heating beyond the recrystallisation point, then gentle cooling under controlled conditions. The overall ability of such metals to withstand stress, their toughness, far exceeds that of resilient, but brittle, quenched steel. And an annealed girder will be seen to neck as it approaches its yield point, clearly demonstrating the need for both stress reduction and active processes to reconstitute its strength.

So where does that leave those working in healthcare, and those wanting to help them?

The stresses of healthcare can take us well beyond the point of elastic rebound. The situations we encounter and the experiences we share can change us, permanently; cyclical loading, and chronic, unrelieved stress, will typically exacerbate the damage. But the way that we deal with these crisis points will strongly influence our psychological, emotional and spiritual toughness.

Traditionally, practitioners, and teams, have used quenching as a means of coping—“It happens”; “Man up”; “Get over it”—and every day I see the brittle hardness that this produces. On the other hand, the annealing properties of reflection are increasingly acknowledged: traumatic experiences, carefully re-explored, can create increased tolerance for the difficult times ahead.

This process can be much wider, and far deeper, than the simplistic reflective templates and cycles imposed by portfolios and appraisals: finding meaning, making sense, uncovering perspective, through creative writing and other artforms, through informal discussions with peers and significant others, or through formal team-based approaches like Defusing and Critical Incident Stress Debriefing.

Most of us have neither the tech nor the talent to portray our mental health graphically, but we can learn to recognise the signs of distress—in ourselves and our colleagues—as we approach the inevitable yield points of our professional lives; we can openly share these indicators; and we can heed the need not only to reduce stress but to find ways to actively remodel ourselves.

For some, remodelling might be achieved through increased engagement with life outside clinical practice—with faith, family, friends; exercise, gardening, cooking; art, writing, music. Others may need time away from stress. For some, professional help may be needed. Importantly, we are starting to see all these as normal, healthy, usual responses to the situations in which we work.

Resilience, toughness, tolerance: there are problems with all these terms, and none of them is a panacea for the effects of stress; and there is much that could be done to reduce the strain of current systems of healthcare; but an emerging culture that turns away from quenching, and towards annealing, represents an important start.