The resilient phenotype: Physicians who thrive despite adversity

Writing the counterpoint article to Pedro Weisleder's commentary on moral injury among medical practitioners has been challenging, largely because I tend to agree with much of what my friend has to say.¹ I am also at a considerable disadvantage because, unlike Dr. Weisleder, I am not a trained ethicist. Thus, I have few options in this debate but to provide a smattering of personal observations in an effort to ensure a balanced perspective.

There is considerable research on burnout among physicians, but moral injury is not as well studied. Physicians are often reluctant to acknowledge concerns about moral injury lest they appear inadequate or weak. Their hesitancy to speak may also be related to a denial of personal vulnerability or to the long-standing stigma surrounding mental health disorders among physicians, a broader problem for another day's discussion.

One point that is seldom mentioned in contemporary discussions of physician burnout and moral injury is that medicine is an intrinsically difficult profession. How could it be otherwise when we so often deal with untreatable diseases, death, disability, social and family turmoil, and patient financial ruin? It is wrong to assume that only modern physicians face soul-scarring difficulties. Previous generations of physicians had far fewer effective therapies and so more often had to preside over hopeless situations or resort to worthless medications or mutilating amputations in an often-futile attempt to save someone's life. Additionally, physicians once faced a socially accepted dual standard of care that was far worse than the present gap between individuals with commercial health care insurance and those with limited coverage: it was once considered completely acceptable for physicians to simply ignore sick poor people. Indeed, physicians who provided a free cattle-call clinic for a few hours each month were usually considered noble for doing so. Surely these circumstances would have engendered moral injury to many caring, thoughtful physicians of the time. While the recently articulated concept of moral injury makes it easier to recognize the outsized role that our health care system plays in creating physician distress, it is naïve to blame burnout and moral injury solely on the institutions of medicine. Being a physician has always been challenging, and it is likely to remain so even if we can address some of the systemic issues.

I have often pondered why some physicians seem to fare so much better than others when facing situations that typically lead to moral injury and burnout. Even within the same medical specialty, in the same institution, and with the same workload, some people remain grounded and productive while others falter and decompensate. From my own admittedly anecdotal observations, the diverse responses of physicians to professional adversity may be partly explained by intangible individual qualities such as resilience, perfectionism, compulsiveness, strength of purpose, and clarity of expectations. This comment is certainly not intended to absolve our institutions from responsibility by shifting blame to the physicians who deal with the woes of organized medicine on a daily basis. It should never be acceptable to make medical practice more difficult than necessary, even for physicians who seem to be thriving. But it is also wrong to ignore these individual physician differences, if only because they could offer practical avenues for helping a distressed colleague. Each physician has unique qualities that will inevitably influence how they react to professional adversity as well as how they respond to proposed solutions.

Some physicians are drawn to medicine because it offers a sense of accomplishment and prestige within their community and their family, while others are attracted by the higher income medical practice offers. None of these motives provides a sustainable reason to become a physician. Medicine is and always has been a tough career. Anyone who thinks otherwise is likely to be ill-prepared for what is, even under ideal circumstances, an often physically and emotionally grueling lifestyle. Regardless of whether the challenges we face stem from the practice of medicine per se, from ill-advised institutional policies, or from a combination of these factors, we should perhaps acknowledge that some people simply do not have the temperament or resilience to thrive in medicine.

Are we sure that we physicians do not contribute to the problems we face, even to a slight degree? The health care system would come to a complete standstill if enough physicians conclude that enough is enough and demand change. The legitimate systemic issues that Dr. Weisleder describes exist in the context of physicians who are collectively unable or unwilling to demand changes. Presumably, this means that many physicians are not totally dissatisfied with their current circumstances or, more likely, are insufficiently dissatisfied to risk their otherwise comfortable existence in an effort to exact change. Even individual physicians may bear some responsibility. While many of us complain about the workload and the lack of time needed to promote personal well-being, few are willing to accept part-time employment that might promote well-being and still allow an income that many nonphysicians would envy. Not all physician jobs would allow such a change, of course, but some of us make a conscious decision in favor of higher compensation instead of opting for a position with more personal time but lower income.

The entrepreneurial nature of the United States health care system predictably incentivizes financial gain, both for institutions and for individual physicians. Efforts to control the resulting high costs, in turn, often lead to questionable documentation requirements and wasted physician time spent pleading for approval of necessary diagnostic studies or treatments. Major institutions shamelessly cherry-pick lucrative procedures, depriving less affluent facilities of needed funds and exacerbating care disparities.² Our piecemeal reimbursement system both rewards and normalizes these behaviors. Altruistic practitioners who entered medicine to help people are often caught in this profit-driven meat grinder, typically with little meaningful input into far-reaching decisions that affect patient care and contribute to physician burnout. But as Dr. Weisleder points out, physician burnout is a worldwide problem, so the unique difficulties of the US health care system cannot be the sole reason for it.

How can we address these pervasive issues to make life easier for physicians? Laying the entire problem at the feet of the physicians is certainly unfair. But it is also unwise to ignore the individual traits that contribute to burnout and limit our ability to cope with moral injury, if only because these individual characteristics may provide improvement opportunities that are far more plausible than overhauling the entire health care system. Celebrating successes, promoting self-compassion, improving self-awareness, and inasmuch as possible aligning personal values with work duties may help some of us avoid a vortex of pessimism.³ We need to cultivate resilience, realistic expectations, and strength of purpose. Doing so will not eliminate the individual or systemic difficulties of medical practice, but it just might enable some physicians to deal with these difficulties more constructively.

E. Steve Roach: Conceptualization; project administration; writing—original draft; writing—review and editing.

The author is the editor-in-chief of the Annals of the Child Neurology Society. The opinions expressed in this essay are those of the author and do not reflect the official policy of the Child Neurology Society.