Failure is always an option

By Daniel Cabrera 

When I reflect on my life as a learner and as an educator, there are several things I wish I learned in medical school and that I hope I can teach to our students. Among them, is the concept and the praxis of grit or resiliency. I didn’t realize about the importance of resiliency until late in medical school, where I started to realize that people who actually make it in life are people who have the mental toughness, emotional skills and the physical ability to conquer daily adversity.

Resilience is a buzz word in many disciplines, including  psychology, management and education. While a growing body of research is trying to understand its nature and mechanics, there are a lot of controversies about what the phenomenon really is and particularly if is a skill that can be taught.

Among the main questions about resilience is whether it is a personality trait shaped by genetic makeup and the environment or whether it is a cognitive skill that can be taught. Several resiliency building programs currently exist (with a spectrum of participants ranging from young children to active military personnel), most of them based on the Penn Resiliency Program.

Why think about resiliency?

As Clinician Educators, we should consider resilience because of the alarming rate of burnout and abandonment of the healthcare workforce in recent years. Most authors tend to believe that our inability to cope with the multiple conflicts of work and life is the leading cause of this schism. A robust set of skills to deal with the intrinsic and extrinsic stressors is critically important. I would suggest that resilience is a protective factor against dissatisfaction and burnout. We need to understand what resiliency is and is not, apply it in our lives and teach it to our students.

What are the key characteristics of resilience?

No one is completely sure with several schools of thought describing different core characteristics of resiliency. In an attempt to organize the current theories, I suggest the following three major domains:

• Ability to recognize the circumstances
• Ability to provide a raison d’etre
• Ability to adapt and react

The first and most important trait of resiliency is the ability to make realistic sense of the environment and to prevent a biased, emotionally-negative interpretation of the current circumstances. Mentally tough people are able to dispel the unrealistic beliefs about adversity; they understand that the emotional consequences of adversity are a function of the interpretation of the situation and not the actual event. Resilient people are realistic and optimistic at the same time, they recognize the adverse situation and try to read it through the prism of the most likely scenario, discarding extremely positive or negative possibilities, which are largely improbable. They know that failure is a dichotomist outcome with an opportunity. They choose to follow the opportunity.

The second trait that defines resiliency is the ability to find meaning, a reason to be or raison d’etre in the midst of adversity. The meaning serves as motivation and allows people to re-adjust their expectations. Further planning of their objectives can lead to more transcendent goal. This goal can be as practical as a grade on a test or as ethereal as true happiness. This raison d’etre provides persistence, but is important that this persistence is linked to a low-anxiety temperament (composure), otherwise minor and major setbacks in the quest for the goal have the opportunity to create significant emotional distress. This trait may largely be influenced by personality.

The third trait is the ability to adapt and react. Understanding adversity and being able to persist is only positive if the person is able to take action. This trait involves discipline, ingenuity and determination; the discipline to craft an action plan, the ingenuity to adapt this plan to the constrained resources available and the determination to carry it out. This is adaptation too, as carrying out a plan with unlimited resources is far easier than adapting to the constraints given by time and resources.

 

How does resiliency work in our daily lives?

Resiliency helps us survive, it prevents burnout and allows a person to stand up after a fall. Dunn et al. describe the concept of coping reserve where each person has a discrete amount of coping skills. Positive factors such as social interactions, mentorship and a raison d’etre replenish these skills, while negative factors such as internal conflicts (personality, external conflicts (interactions) and resources constraints (money, time, opportunities, etc.) drain this reservoir. Fragility functions as an evacuating valve (here fragility is understood as vulnerability), while resilience works as a input valve, providing renewed skills of coping. The goal of every person facing adversity is to aim for achievement by allowing resilience to replenish the reservoir, while decreasing negative inputs by stopping the fragility-lead drain that leads to burnout.

Why teach about failure and resiliency?

Failure is a constant in our lives and careers. We fail for many reasons, ranging from our inattention to (complex) errors or as part of exploration (positive failure). As Clinician Educators we have to ensure that our learners can face failure and learn from it, both in their academic and personal lives. We all need to understand that our failures will be as common as our success.

Resiliency training is necessary to limit attribution of negative feelings to the events leading to failure. It is important to understand that our beliefs guide our emotions and not the objective appraisal of the event. Failure is not always negative, failing is acceptable as long as there is a framework for detecting failure, learning about the complex systems and factors leading to it, and creating a solution to overcome it.

Adaptation is a major domain necessary to conquer failure and drive achievement. Creativity, inventiveness, ingenuity and entrepreneurism define this capacity. Adaptation requires two important elements, one is the ability to interpret the situation correctly and the second is persistence to achieve an ultimate (higher) goal. When life gives you lemons, you make lemonade not necessarily because you like it, but because you are thirsty.

Medical education needs a curriculum on learning and teaching resiliency. There is a lot we can learn and adopt from psychology and management theories, but a basic resilience framework can be outlined as:

• Understand the environment
  • Recognize the circumstances
    • Approach with realistic optimism
  • Adversity is common
    • Consequences arise from the event
    • Belief and emotions should not bias the interpretation of events
  • Failure is dichotomous with opportunity
    • Choose opportunity
• Understand the raison d’etre and yourself
  • Create a raison d’etre
  • Adjust goals to the raison d’etre
  • Acts are only significant as a function of a goal
    • The goal is set and varies from person to person
  • Create and nurture coping skills
  • Persistence requires discipline
• Understand the plan
  • Ability to adapt and react
  • Adapt to resource limitations
  • Foster ingenuity to adapt to new scenarios

 

Our learners need to develop true grit. They need to understand that long lasting success and achievement requires adaptation to adversity.

Figure. The Coping Reserve. Original, adapted from Dunn et al. 2008.

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