The concept of resilience is a subversive way to push depleted healthcare workers past their limits.
There is an image circulating on social media appearing to show an email from the management level of a UK hospital. The missive admonishes and embarrasses staff for negotiating higher pay to cover rota gaps and signs off with a line that bluntly illustrates the tightrope which healthcare workers will seemingly forever walk, “There is a moral ethic to being a doctor which I would like to remind you of.” And with that, the few measly crumbs of morale left to the recipients are rudely swept from the table.
While I cannot attest to the veracity of this message, I do not doubt it. I can say to no great surprise that similar messages have come the way of my colleague and I with quite alarming frequency. Even after the sacrifices made during this pandemic, it seems sympathy can be quickly found to be in short supply and withdrawn. It has been before.
In 2016 junior doctors in the UK were facing a 15% pay cut with the removal of safeguards limiting our working hours. From the inside, the disastrous effects on patient safety and staff morale were obvious. During that time, 5 years after qualification, I calculated that I was making approximately £13 an hour. My mental and physical health were already shot (and plummeted further as the dispute wore on). Despite such cost I never wanted to be paid more, but when the screws were being tightened, like most junior doctors, I decided to speak up, protest and join strike action. (Eventually, I decided to move to South Africa.)
Members of the government, public and even if the medical fraternity repeatedly called into question the sincerity with which we viewed our work. Older heads piped up the like the belligerent old men of a Monty Python sketch telling us how we didn’t know how good we had it. Gone was their era of 25 hour days, 8 day weeks and being force fed lumps of coal by matron for breakfast.
Above all, we were accused of abandoning the moral and ethical duties we had to our patients. This moral line marks the boundaries of our cage; the ties that bind us to the sacred aspects of our profession also seemingly bind us from asking for fairness. The shining virtues of decency, public service, morality, and the value of human life are invariably turned on us by those with nefarious intentions.
There are few healthcare workers thinking that (if and) when the current global crisis is said and done, that those in power will turn around to bestow a reward beyond the symbolic or insulting. On the contrary, when deemed necessary, cuts will be made, services will be strained and the people within those services will be expected to bend and stretch further.
After all, it is our moral duty to make it work.
So where does resilience come into play? Resilience when used in the healthcare context, describes an individual’s ability to withstand the inherent pressures of the role, contributed to in no small part by working conditions. Health Education England, the board in charge of training for doctors imagines its subjects as resourceful little sponges, problematically describing it as “the capacity to absorb negative conditions, integrate them in meaningful ways and move forward.”
To be perfectly clear before we go on, it is important to point out that resilience is not a hard skill. It is not something easily taught, and it is not a reproducible attribute. On the individual level, it is a complex quality influenced by myriad emotional and social factors. What much of the discussion on resilience in the healthcare sphere seems to overlook is the importance of the environment in which we as individuals operate. Take a hardy cactus from the desert and place it in Antarctica. How long will it last?
Dame Clare Gerada wisely points out in her book Beneath the White Coat, that resilience is not wholly positive, encompassing traits such as ruthlessness and selfishness. I remember witnessing, as a first-year doctor, a vicious argument between two surgical trainees competing over time at the operating table; both needed more procedures on their portfolio for upcoming interviews. I knew there and then that I could never thrive in a surgical job, unable to step over someone else to grasp at limited opportunities.
Training to suffer better
The present model of resilience is a top-down model in which the institution pressurises the individual and asks us what we are made of. How well can we bounce back after an insult, or a shock? Will we flinch when hit or will we absorb it?
This places us in one of two camps: those that cope (at least temporarily) and those that don’t. One group adapts while the others are targeted for training. This is a downstream intervention in which the institution turns to those that have ‘failed’ it to probe and plug the faults and characteristics that made them buckle. Resilience training asks, “how can I make you better equipped to deal with the punishment?”
For the medical field, this is a peculiarly short-sighted approach in which the system holds up a mirror to those non resilient individuals without ever looking at the root cause, without holding up a mirror to itself. Perhaps it is because it cannot bear to look or because it thinks it cannot afford to.
The simple fact is that as individuals within the profession we are already resilient. The last two years have been a global demonstration of that fact to a wider audience. There should be no doubt as to how seriously we take our roles. Everyone has a breaking point and the system and culture, unless changed will push everyone there eventually. Until then, we will invariably bend and flex to ensure business as usual. If not, we will face charges of abandoning our moral stations.
The trap of healthcare workers and in particular, doctors, is that they are viewed by the public as well educated, advantaged and thus undeserving of sympathy. If a factory owner found that her assembly line employees were falling ill due to toxic fumes generated by her plant, can you imagine if she were to send them to a poison acclimatisation workshop? If such mistreatment of unskilled, low paid workers from disadvantaged backgrounds were to leak out to the public, there would likely be an uproar of support and rightly so.
However, demanding better conditions and pay from a position of perceived privilege is a dangerous tight rope to walk, one in which sympathy can disappear quickly. The government under Cameron and Hunt wrote the playbook for others to follow when they used this argument on us with expert precision. Added to the argument of moral absolutism, the options available are reduced to the following: adapt, burn out or walk out.
In reaction to insensitive solutions that place the onus on our overburdened shoulders the easy temptation is to demand that those in charge act for us. But, to absolve ourselves of responsibility and hope that others have our best interests at heart robs us of agency in designing the world we want to build for the future of healthcare.
Yes, the system, the institutions and the culture must change but these are not abstract entities, these are things of which we are the vital ingredient. Trite as it may sound, it is of utmost important to realise that we are the system, the institutions, and the culture. So, like all meaningful change, it must begin at home, with you and then with your team, then with your department and so on.
While these are individual level solutions, they are not aimed at making us a better fit for the system but about how we embody the system so that it naturally becomes a better fit for us. Rather than bending and accommodating, it is time to be firm, to stand up and demand better. The time is ripe to become aware of your worth and remind your colleagues of theirs. Not only in a monetary sense but in all senses. The time is right to ask yourself not only what you should be paid but a far more important question, ‘what is this costing me?’