Individual Resilience
 
            I have discussed the need for organizational resilience (and flexibility), but organizations are made of people, so what makes individuals resilient? Buckingham has reported research findings examining this question.[1] He found no correlation with age, gender, or nationality. He found resilience is a reactive state of mind created by exposure to suffering and secondly, the more tangible threat the more resilient we become. But too much exposure can be overwhelming and is associated with burnout, depression, substance abuse and other dysphoric states.
          Shanafelt and associates have reported a study of Stanford University physicians correlating burnout, professional fulfillment, and self-care practices with leadership effectiveness.[2] They used standard surveys to measure the first two, which tend to move in opposite directions. Likewise, they used a standard measure for sleep deprivation.
 
        “Self-valuation consists of a growth mindset (responding to errors and personal imperfection with a desire to learn and improve rather than shame) in combination with the ability to prioritize self-care and personal well-being. Self-valuation was assessed using the 4-item Clinician Self-valuation Scale. Responders indicate their experience with indicators of poor self-valuation in the past 2weeks using a 5-point Likert scale (0 indicated always; 4, never). Using the standard scoring approach, a total self-valuation score ranging from 0 to 16 is calculated by summing the score of the individual items (with higher scores indicating more favorable self-valuation)…
          All participants were asked to select the name of their immediate supervisor from a drop-down menu that listed the names of their department chair, division chiefs, and medical clinic directors. They then evaluated this leader using the Mayo Clinic Participatory Management Leadership Index. This instrument was designed to evaluate leadership behaviors associated with team member engagement, including dimensions related to inclusion (treating everyone with respect), keeping people informed, soliciting input, empowering team members, nurturing professional development, and providing feedback and recognition. The original 12-item index was subsequently revised to a 9-item instrument.     Each item is scored on a 5-point scale (1 indicates strongly disagree; 5, strongly agree), and the scores from the individual items are summed to yield a total score (possible range, 9-45, with higher scores indicating more favorable leadership behavior). The aggregate leader behavior score for each leader evaluated was determined by the composite evaluations of all responding physicians who they supervised.”
 
            When comparing survey results with reported leadership effectiveness, they found burnout explained 9.8% of the variation in the leader’s score. Self-reported fulfillment accounted for 7.9% of the variation in the same score. The authors conclude self-care and avoidance of burnout need to be part of every leader’s toolkit. So, self-care in the face of chronic stress, and experience with a specific, credible threat are associated with improved resilience based on these two studies. But other factors are also involved.
            I saw a television program the other day[3] where a former coal miner, suffering from black lung disease (pneumoconiosis), was asked whether he supported a return of coal mining to his economically distressed town in eastern Kentucky. His answer was an emphatic yes. The interviewer pressed him noting both he and his father had black lung disease and younger miners would also contract the disease if mining resumed. The miner persisted in his belief that the return of coal mining was essential. The interviewer was then asked if the man wanted his own children to go to the mines. At this point he became tearful and said no. In a voiceover, viewers were told the man had died of his disease shortly after the interview.
            Why was the miner so convinced? I don’t know, of course, but I can think of several possible explanations. First, mining was all he knew and perhaps all he could imagine. He may have been unable to conceive of a viable economic future for his community without coal mining. Second, mining has always been a physically demanding and dangerous occupation. Just like for soldiers, an esprit-de-corps often develops that promotes toughness, or resilience. And just like combat veterans, sometimes life without that spirit is flat. Third, he knew he was dying and perhaps had thoughts that all his work and sacrifice had been a mistake. This is suggested by his reaction when he admitted he did not want his children to follow his example. There may be other reasons, but I think the point is clear. When the threat is grave and immediate, fear is a normal reaction. Some people, perhaps 10-15% of the population in the first study, react resiliently, but others become paralyzed or resistant to change
            I wonder how much of the chaos in our health care organizations parallels the reactions of the miner. Do we cling to what we have known because we have difficulty imagining a different future? Do we recall our former attitudes and associations with suspicion that much of our efforts were in vain? A medical school classmate’s father was a beloved internist in a small town in rural Alabama. At our 25th reunion another classmate opined things were more complicated now than in Doc’s day. Bill listened to all this and said, “Yes, but he buried his share of mistakes, too.”
            If we are to adapt our organizations and our systems we need to acknowledge the role of fear, both individual and collective. Those who are trying to lead need to resist demonizing those who are unable to make changes due to fear. Calling them ignorant won’t help anything. What may help, though, is for leaders to acknowledge their own fears, but also acknowledge things weren’t really all that golden in the past. Finally, a more thorough knowledge of history might help us realize the present is always imperfect and the future is always uncertain. Resilient people and resilient organizations find ways to define their pole star so as to orient their attitudes and behaviors toward their true north.
 
22 November 2020


[1] Buckingham M. What Makes Us Resilient? 29 September 2020. Accessed 30 September 2020 at https://hbr.org/2020/09/what-really-makes-us-resilient.html.

[2] Shanafelt TD, Makowski MS, Wang H., et. al. Association of Burnout, Professional Fulfillment, and Self-care Practices of Physician Leaders With Their Independently Rated Leadership Effectiveness. JAMA Network Open. 2020;3(6):e207961. doi:10.1001/jamanetworkopen.2020.7961. Downloaded 17 June 2020.rinted)

[3] https://www.pbs.org/independentlens/videos/jonathan-scotts-power-trip/. Viewed 16 November 2020.

Further Reading

Barriers to Innovation
Innovation is critical for organizational survival, but internal and external forces make it difficult.

Crisis
To paraphrase Donald Rumsfeld, you fight coronavirus with the healthcare system you have, not the one you might wish you had.

Experimentation
Experimentation may seem risky, but is essential for progress. How do we do it safely in challenging times?

Heroes
Is the heroic age of medicine over? If not, what would heroism look like?

Leadership Lessons From the Military
Lessons from leading the military in Afghanistan have implications for which medical organizations will thrive in the current turmoil.

On Resilience