With close to half of American pediatricians reporting at least 1 symptom of burnout, our professional sustainability is at risk.1 Interventions mitigating burnout have been proposed at both individual and systems levels, with variable success.2 Many interventionists target professional resilience, but few formally integrate resilience theory. Furthermore, many interventionists suggest that resilience is defined by the absence of burnout, but I propose that resilience is more than that. Would we be more successful if we endeavored not only to avoid burnout but also to reclaim the value and meaning behind our professional calling?

“Resilience” connotes an ability to maintain physical and emotional well-being in the face of adversity; however, measuring and operationalizing it is complicated.3 Traditional resilience theories fall into 1 of 3 categories: Resilience is either an intrinsic, perhaps immutable trait (eg, grit), a process of coping or adaptation (eg, meaning-making), or an outcome (eg, the absence of burnout).3 Each of these conceptualizations is inherently problematic as it translates to medical professional resilience. Trait definitions fail to incorporate skills and perspectives acquired in training and practice, and process definitions ignore the integration of preexisting personality characteristics that influence how we develop those skills and perspectives. For example, we may need both grit and meaning-making to successfully navigate a medical career. Defining resilience as an outcome does not recognize the potential for change, nor does it integrate concurrent but conflicting measures. A resident on a particularly difficult rotation may feel burnt-out today but may identify important lessons and career-inspiration tomorrow. Which relative outcome or time point defines her resilience?

An alternative conceptualization is that resilience is “the process of harnessing the resources we need to sustain well-being.”3 Here “resilience resources” include (1) external resources (eg, “Who supports me?” and “Whom do I call when I need help?”), (2) internal resources (eg, “What are my strengths and skills?” and “How can I develop them?”), and/or (3) existential resources (eg, “What should I learn from this?” and “What I am a grateful for?”). Note that these categories integrate traits, processes, and outcomes. For example, internal resources include both traits like grit and processes like learned time management. Existential resources include a process of meaning-making within the context of concurrent “outcomes” like burnout.

Building medical professional resilience may then be easier if we rely on this more actionable theory and examine specific barriers to harnessing each set of resources, in turn.

External resources include social supports outside of medicine (eg, church groups or extracurricular clubs), but they must also include professional peer support. Indeed, sharing experiences and reflections with colleagues reduces burnout and promotes well-being.2 Unfortunately, the intensity and time commitments associated with medical training and practice may preclude such relationships. Many young physicians adopt a “survival” strategy of delaying personal relationships until some unforeseeable “easier” future.4 This practice can become a career-long coping strategy, translating to a lack of supportive personal and professional relationships.

Furthermore, common physician experiences and personality characteristics may also result in barriers. For example, inherent competition, scrutiny, and fear of criticism may make it challenging for students and professionals to ask for help or share their personal struggles. In a 1982 poll of 100 randomly selected physicians, all possessed at least 1 (and 85% possessed at least 3) of 5 Diagnostic and Statistical Manual of Mental Disorders, Third Edition criteria for compulsive personality: restricted ability to express warm emotions, perfectionism, insistence that others submit to one’s way of doing things, excessive devotion to work (to the exclusion of personal relationships), and indecisiveness.5 The resultant feelings of guilt, doubt, and an exaggerated sense of responsibility encouraged diagnostic rigor but impeded social supports.

Evidence-based examples of internal resilience resources include personal traits (eg, grit, optimism, sense of humor), processes of adaptation (eg, coping styles, mindfulness), and learned skills (eg, goal-setting, stress-management, constructively responding to criticism, cognitive reframing, intentional efforts to achieve work/life balance). Different internal resources predominate for each of us. And although some seem universal in medical professionals, not all are consistently adaptive. For example, all trainees likely use goal-setting skills to achieve the successive milestones of medical school, residency, and fellowship. However, solely working toward future benchmarks may become problematic after training is complete because clearly timed milestones no longer exist. Early career professionals may need help identifying other forward-looking goals or motivational factors to sustain themselves.

Authors Sandberg and Grant6 suggest “3 P’s” that can be used to describe common responses to adversity that inhibit internal resilience: personalization, pervasiveness, and permanence. These may resonate with physicians. Imagine a case of a medical error: personalization is the belief that we are solely responsible for it, pervasiveness is the idea that this single mistake will impact all areas of our professional (and nonprofessional) lives, and permanence is the belief that consequences of this mistake will last forever. The ability to identify and reframe each of the P’s may therefore be a critical internal resilience resource for medical practitioners to develop; however, few receive directed training in how to do so.

Existential resilience resources embody practices such as meaning-making and finding gratitude. In pediatrics, these may include remembering why we chose the career, appreciating opportunities to be present during a child’s illness, or simply prioritizing impactful work. In a national survey of nearly 1300 American physicians, “personally meaningful hours” of work per day were linearly associated with both career and life satisfaction, whereas extrinsic factors like income and practice location were not.7 What constitutes a personally meaningful work hour? For some, this may be an hour spent in education or scholarship. For many, this will be in direct patient interactions and providing a service to those in need.

In any case, identifying meaningful work requires self-reflection and time. Finding this time may be particularly challenging in medicine. Just as busy schedules and long task lists preclude personal relationships, they also may be deterrents to self-care. Concepts of spirituality, including the non–faith-based exploration of personal meaning and purpose, are rarely mentioned in medical training. Ironically, evidence suggests that these and other existential resilience resources, such as self-awareness, reflective writing, and communication-skills (designed to teach empathy and emotional connection with patients), are associated with reduced burnout.2 Taken together, increased attention to existential resources may be highly beneficial in professional medical careers. We simply need opportunities to develop them.

How do we promote each of these sets of resilience resources? We can build external resilience resources by cultivating professional relationships, sharing common experiences and challenges, and nurturing a culture in which peer support is systematically modeled. We can build internal resilience resources by acknowledging adaptive personal traits while making deliberate efforts to develop skills such as stress or time management. Finally, we can build existential resources by finding time to create our own meaningful professional narratives. This may be as simple as asking oneself, “What do I find most meaningful in my work?”

We can no longer ignore the fact that high rates of burnout and job dissatisfaction are putting the pediatric workforce at risk. It is time to think beyond “avoiding burnout” and aim higher. Integrating resilience theory may provide a new framework for us to improve overall morale and professional experiences. By harnessing external, internal, and existential resilience resources, we may reclaim the calling that brought so many of us into medicine.

FUNDING: Dr Rosenberg is supported in part by the National Institutes of Health National Center for Advancing Translational Sciences grant KL2TR000421. Funded by the National Institutes of Health (NIH).

Thank you to Drs Colin West, Mike Linenberger, and Sallie Dacey for inspiring this essay at the 2017 University of Washington Art of Medicine in Hematology/Oncology workshop.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.