Thriving in scrubs: a qualitative study of resident resilience

The concept of “becoming a doctor” emerges throughout the interviews as the core construct within professional resilience. Residents shoulder the frustrations and challenges of the work as they reach towards high ideals for the profession and high expectations for themselves. When the challenges are overwhelming or the ideals feel particularly far away, they describe feelings of burnout. They find solidarity and consolation through connection with others in the medical community, especially with fellow residents. As one resident puts it, “medicine is a team sport. Everyone here has the same end goals as residents to offer the best care to our patient that we can” (PGY-3, Subject 9). The other residents are “really the only people who understand what’s going on in a very real way.” (PGY-4, Subject 10). Residents frequently used war metaphors and describe each other as being in the army together. But not all residents bond with the others, and one struggling resident described not feeling support from this team spirit, saying, “you’re constantly working with one another. Everything feels like a group project. I’ve always hated that.” (PGY-2, Subject 20).

Residents frequently express stress and frustration when there are conflicts within the resident team or with allied health professionals. Even among residents, competitiveness and hierarchy simmer beneath the surface. Some residents, more commonly junior residents expressed less comfort exposing their vulnerabilities within the medical community. One says,

There’s a tendency in medicine to not show weakness and I think that that’s very hard to overcome. There are like a couple of people who I would feel comfortable talking to about really feeling bad or if I have very heavy things on my chest, but not everybody. (PGY-2, Subject 21).

In addition to hierarchy and competition, which coexist in the resident team, the residents also personally rely on each other to cover the clinical services. When one resident’s personal needs cause an absence, others must work harder.

Thus medical relationships, while providing a major source of support to residents, nonetheless reflect a surrounding culture that espouses herculean ideals. Many residents look to their relationships outside of medicine to provide more balance and accommodation for their own needs and imperfections. The tension between professional and personal identities reveals itself as residents talk about “normal people” who do not work in healthcare. The residents both pride themselves in having a distinct professional identity, and also envy these others. From the residents’ perspective, normal people are permitted to focus on their personal needs, while doctors feel guilt when attending to theirs.

Families and friends provide strong support to the residents, and are seen as a counterbalance to the professional world. One resident describes speaking to her boyfriend, saying:

When I’m like, ‘oh, this is such a terrible thing, this day was crazy,’ he’s like, ‘but you’re fine and you’re here and everything seems like it’s okay.’ And then you’re like, ‘yes, in the grand scheme of things not faxing that slip in for the [surgical] instruments was totally fine.’ (PGY-3, Subject 4).

These perspectives from outside the medical world provide useful counterbalance to germane work stresses, but residents also report keeping some of the more traumatizing experiences private. One describes not wanting to burden her partner with “the sad things that we see and are adapted to” (PGY-2, Subject 22). Building relationships and families during this stage of adulthood is developmentally important, but can be challenging to balance with work. As one reflects, “it’s been hard to be an OB/GYN and feel like everyone around you is having babies and moving forward in their lives and you’re at this place where residency doesn’t allow you to move forward in your personal life” (PGY-2, Subject 20). Residents place a lot of attention on finding crossroads between their personal and professional identities. When these efforts are successful, they are more likely to portray resilience.

For many residents, the call to medicine comes from early life experiences, which inform their professional aspirations and identity. Residents describe parents who were doctors, or who prized hard work and high achievement. As one resident says:

Wanting to do well and succeed was instilled by two successful parents who gave me a lot and wanted me to do well and succeed, wanting to make myself and my family proud. (PGY-2, Subject 22).

This achievement-oriented approach to the work influences how they engage with obstacles.

In the face of difficult experiences, residents often reflect on their future goals or take pride in what they have learned through prior struggles. Persistence and a “positive attitude” are prized values. One resident remarks, “If you have a positive attitude, you’re enthusiastic, and willing to work hard, that can get you through pretty much anything” (PGY-4, Subject 8). The same resident says that “the hardest part of residency is you go from 20-plus years of being in school where you get a gold star, you get an A, you get these pats on the back.” In clinical work, where these rewards are not always visible, the residents can get discouraged. During residency, “this is just the expectation, this is what you’re doing, this is a job’ and there’s no one to be like, ‘wow, that was a great job you did today.” (PGY-4, Subject 8).

Some residents identify moments where they discover private rewards in their connections to patients. One says,

My favorite, which happens when nobody’s looking, is when the patient says, ‘Can I come back and see you? You’re so good. Thank you so much. That was the first time somebody’s explained this to me.’ (PGY-2, Subject 6).

Reframing these connections as the rewards of their efforts requires focusing on the patient and not their own aspirations. Some residents describe other-motivated motivations in the form of values of duty, responsibility or altruism. Often this appeared in a motivation to work with underserved populations. Taking a step back to see the value of the connection to the patient provides another personal support for the work. One resident says, “what is more intimate that being in the room and delivering somebody’s baby…we appreciate how intimate that moment is, and how special it is to get to be a part of it. (PGY-3, Subject 9) This process of finding something special and important within the work itself and the patients, rather than looking for evidence of the doctor’s achievement seemed to provide a way to stay engaged with the professional calling despite struggles endemic in the work, and without obvious external rewards for achievement.

Residents make connections between their own wellbeing and their ability to connect with patients. When they are not feeling cared for themselves, it is harder for them to feel empathy for patients. One resident says she lost her empathy when feeling burned out. She says her peers, “who are further on down the line say that it comes back, when you’re more rested” (PGY-2, Subject 20). There is a perceived conflict between being the caregiver and caring for themselves. As one says, “we all give out great advice to each other but we don’t always take it ourselves” (PGY-2, Subject 5). Reflections on self-care often focus on basic needs of food and rest, attention to nurturing the physical self. Many recognized intense levels of stress around them, but feel there is little room reflection and processing the stressful and traumatic aspects of training. As one states, “after a bad outcome, there is a little bit of repression because you have to run to the next thing. There’s not a lot of time to process in the moment.” (PGY-2, Subject 21) This kind of short-term compartmentalization is widely endorsed as necessary to function in the fast-paced and demanding clinical environment. A PGY-4 resident recalls, “no, I cannot do this right now. I need to come back to this because I'm not thinking clearly about it. I will come back to this and I will deal with it” (PGY-4, Subject 10). Later, if the incidents are unpacked, the residents sometimes uncover unwanted self-critical and perfectionist thoughts. One resident says, “I tend to tell myself that, no, that was horrible, you know, you could have done this better, you could have done that better” (PGY-1, Subject 2).

Residents see both negative and positive role models among senior residents and faculty, and many recognize that cultivating effective self-care and coping mechanisms are important to avoiding cynicism. Surprisingly, despite stigma and a medical culture that discourages showing weakness, reflections on mental health services were common and largely positive. Residents display comfort with having sought and benefited from mental health treatments. The immediate requirement to prioritize patient before self in a complicated situation requires an effective means of processing the experience later. For some, they do not revisit these experiences for themselves, and the protective boundaries build up, distancing the doctor from the patient. Loss of empathy threatens the patient but also removes an important source of motivation – that connection – from the doctor.

Resilience emerges as the residents engaged with challenges. For those who developed resilience through difficult experiences prior to residency, the trials of residency: struggling with self-doubt, the weight of responsibility and making mistakes, appear less overwhelming. For many in this group, control and persistence characterize their approach to problems. But some of the adversity and uncertainty experienced in residency does not present a problem which can be solved. When patients suffering cannot be explained, when complications cannot be reversed, when treatments are not effective, these experiences shake their conviction in the profession.

In the face of daunting challenges and difficult clinical encounters, many describe distance from their spiritual base, even if they endorsed a prior religious or spiritual orientation. One resident describes the way this has eroded during training, saying:

I think a lot of people would like to believe that there’s something out there that’s more than themselves. I feel like working in healthcare and seeing all the bad things that happen to people makes that hard. I don’t know if you can see [these things] over and over and over again and think, ‘oh yeah, this is definitely the plan.’ (PGY-1, Subject 1).

For many members of this group, residency is the first point in their lives when things did not follow their own “plan”. Learning to tolerate these experiences and find other ways of managing stress beyond control and persistence is a big part of the path to resilience for many of these residents.

These concepts generate a dynamic and developmental model of resilience in obstetrics & gynecology residents that resembles a growing organism. Represented here by a tree, (Fig. 1) the core of resilience is the process of becoming a doctor. The roots emanate from family and community values, and the tree reaches upwards towards archetypal professional values and aspirations, represented by the sun. The root bed expands to connections within the medical community, and deepens through connections to patients and the work. Storms of adversity, uncertainty, challenges and value conflicts blow through and shake the tree, but also provide water that allows the tree to grow. Leaves represent the fuel for growth, both the sheer determination embodied by this group as well as development of coping mechanisms which expand the capacity to grow. A watering can demonstrates the ways that programmatic interventions and positive culture might further cultivate the evolution of this growing entity.