Now more than ever GPs have to be mindful of their own wellbeing in the face of the pressures brought by the COVID-19 pandemic. If our PPE gear is essential for our physical wellbeing, PPE for our minds is no less important!

In this common effort to allow us to look after our patients safely, several online resources on resilience and wellbeing have been made available and practice teams have been mindful to share best practice.

Here, I collate my learning from GP resilience resources as well as insights gathered by my colleagues during the course of the pandemic. Useful resources are also highlighted at the end. I hope that these practical top tips and resources will help you and your practice become more resilient today.

• Resilience isn’t just about ‘remaining graceful’ under pressure
• Healthcare professionals face specific challenges, which can affect their resilience
• Doctors under extreme stress are unable to do what is expected of them as professionals so it is important to be aware of the signs
• Resilience training is key to avoiding burnout
  • Tips to cope ‘in the moment’ when having a very stressful day
• The idea of resilient organisations or team resilience versus individual resilience
• Recognising factors that can affect GP resilience

Practical tips on increasing resilience Organisation level – the resilient GP practice  Personal level – the resilient GP

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Resilience isn’t just about ‘remaining graceful’ under pressure

Resilience is becoming an increasingly common word used in the medical community. It is not just about preventing burnout but how to remain graceful/open under pressure and stay healthy and focussed. It is a balance between things that wear us out and things that keep us joyful.   

Stress is an interesting word that, in the physical world, can be thought of as applying directional pressure objects. When you stress people, they either tend to bounce back or bounce forward following an episode. Resilient people don’t tend to have an easier time, but the key difference is that they adapt in a healthy way; however, some people do not bounce back into a good shape or react in a healthy manner. The coronavirus pandemic has put the NHS and healthcare professionals under enormous stress and so providing support to keep people healthy is vital to the bounce back once we start to move towards some semblance of normality.

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Healthcare professionals face specific challenges which affect their resilience

Healthcare professionals are challenged because the daily work of medicine is very demanding, and they soon encounter difficult clinical presentations in their careers. They are required to be cognitively effective in highly distressing situations, even when they are tired or stressed at all times of the day or night. 

There can be an ingrained culture in the healthcare world that doctors should just deal with the stresses that are presented to them. They are just expected to perform. Doctors can deal with stresses in a number of ways, but the lack of time can mean that many do not consider ways to promote and nurture their resilience.

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Doctors under stress are unable to do what is expected of them as professionals

Stress can cause a number of physiological responses:

• Persistent upregulation of the sympathetic nervous system that, over time, is likely to cause illness
• Being highly activated and feeling unsafe will trigger the flight or fight response
• High levels of adrenaline and cortisol for long periods may prevent a healthy bounce back following removal of the stress
• Sympathetic hyperarousal reduces friendliness and empathy, key traits important for doctors.

Heart rate variability and muscle sensitivity can be measures of the autonomic nervous system.

Stress can impact the doctor–patient relationship:

Humans are emotional creatures and are hard wired for emotional intelligence. They are sensitive, empathic and are good at reading others. However, this can be easily lost and long-term stress will effectively shut down these systems.

When we meet strangers, our empathy is reduced. Interestingly, GPs who have personal lists and therefore know their patients more personally, tend to cope better and maintain their empathy during consultations. However, personal lists are now becoming less common ways of working in GP practices so patients are less well known and interactions can be more transactional.

It is also important to remember that GPs and patients can pick up emotions/stresses from each other during consultations. This may be amplified if they also do not know each other and are meeting for the first time discussing very sensitive or emotive topics.

Tips to addressing guilt in patients For example, in those who are furloughed or shielding and not able to work during the pandemic or are working very hard and leaving their own children behind. Ask - What purpose is this guilt serving? Remind - It is a marathon, not a sprint Explain - We are all cogs in the wheel Advise - Focus on what you can do now, not what you can’t

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Resilience training is key to avoiding burnout

Burnout is that the end of the line of chronic stress. It can be a result of spending long periods of time in stressful highly activated situations. In order to cope, we begin to activate both the sympathetic and then the parasympathetic nervous systems.

But, dissociation begins after a period of time and that is when where no pain or emotion is felt.

While burnout is a state of moving between high activation, feeling bad, to low activation, still feeling bad, resilience is when we move from a state of high activation, feeling bad, into a calm and restful state, feeling good – like a safe “cave”. It is important to try to find this restful state to maintain resilience.

Tips to cope ‘in the moment’ when having a very stressful day Recognise what is happening, be in the moment, take control of the next 10 seconds Step back; try: 5 things you can see, 4 things you can touch, 3 things you can smell  Slow breathing down – take 2 or 3 really deep slow breaths  Focus on 1 step at time – 1 patient at a time.  If you feel overworked – don’t internalise and take this home. Acknowledge it and pass the message up The bravest leaders can express their vulnerability Don’t pretend to yourself all is okay if it’s not

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Resilient organisations versus individual resilience

Resilient organisations have strong processes in place to allow employees to be free to work in a professional way without having to push against the system to get the job done. Places of work that make people feel they are on a conveyor belt is dehumanising and is toxic. If the organisation itself is in flight or fight mode, then this puts the individuals into this as well.

Compassion or resilience targets don’t really work in organisations. Targets are ways that the organisation feels they are addressing staff resilience, but it is better to embed support and resilience into the whole team.

Individual resilience involves having coping strategies and techniques to cope following a stressful situation, e.g. breathing or mindfulness. Using techniques like this can allow the person to reduce down their heightened emotional state and reach a safe, calm place again.

Some people react aggressively when stressed or burnt out. Don’t be afraid to check in with these people and check that they are okay (or get a third party to do this). However, we should not have to tolerate bad behaviour or aggressive responses. 

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Recognising factors that can affect GP resilience

It is well known that early life events can result in reduced resilience and dysregulate our affect. Many practitioners will see patients who have had difficult early lives and hence find coping with stress when they are older much more difficult. So, experiences have an impact on resilience, but it is also important to note the effect that genetic makeup has in addition. Genes do play a part.

However, it is possible to teach and support people to have greater levels of resilience; how to prepare and importantly how to recover. Providing this support allow healthcare practitioners to communicate more effectively and maintain an empathic response to challenging situations.

People with positive emotions/emotional flexibility are seen to be the most resilient. They are able to recall and talk about positive things even when bad things have happened. This allows people to recover and grow as they are faced with stress in their lives and workplace.

There is evidence that people who practise mindfulness compassion meditation feel better about themselves and perceive that other people like them more. If you feel that others like you, then resilience is increased. Social engagement is also improved, which is a key skill for doctors.

It is interesting to note that personal resilience can be affected by the work experience/pathway. For example, it may come to a point in general practice where you feel you are as good as you will ever get with no perspective for new challenges. This can be in contrast to hospital careers where it can take longer to move through training grades and there can be more avenues to learn new skills. It is important to recognise that this lack of challenge can be detrimental to resilience and work satisfaction, but this can be remedied at an organisational level, e.g. by continuing to learn as a team and allow people to develop their skills into other areas.

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Tips on increasing resilience

Organisation level – the resilient GP practice

Ensure appropriate workload management. Remember that post-traumatic stress may come after the pandemic calms down Provide a space and time for staff to be able to calm down, for example through breathing techniques (long outbreaths and shorter inbreaths), mindfulness, a time of reflection during the day (“Cave time”) Provide support as a team that deals with the resilience of each member Try to have a professional buddy to provide support to each other. Leaders need a ‘go to’ person too Partners or managers should have chats with the staff to check-in and give staff a proper thank you if they have done well Show that you care: Ask how staff are doing, give them the nudge to seek support Encourage time for reflective practice to discuss areas such as the emotional impact of the pandemic A structured, properly supervised peer support system at work is very helpful Organise team coffee/lunch time in practices Encourage staff to take annual leave and proper breaks Consider working on career progression for team members Provide support for trainees, including time for themselves, to allow personal growth. Courses to support their development are important

Personal level – the resilient GP

Check-in and acknowledge how you are feeling right now Make time each day to think how you are feeling and to be proactive in protecting your mental health Tools and resources can be found on the wellbeing and coping website, which is co-funded by NHS England Aim to not stay in the consultation room for long periods of time without coming out to link with colleagues. Meet with colleagues during the day to socialise or talk about challenging cases While it is important to be emotionally available, ensure you regulate this to prevent large swings up and down Recognise that many patients who come through the door are people in stress for whom there is no clear diagnosis. Allow them to offload their stress but try to visualise them taking it away with them as well Be prepared to manage unrealistic expectations from patients. Practice patient groups can work to help communicate what can be provided by practices and what cannot Recognise that general practice is possibly the most stressful of all careers in medicine and support your colleagues! Wrap plan – Write down and answer the following: What do I enjoy doing? What makes me feel good? What do I need to avoid doing to stay well? When am I at my best? What do I need to do less often? PPE for the mind: Connect, Be active, Take Notice, Keep learning and Give. Finally, try to practice what you preach!

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References and further resources

• GP Wellbeing resources—RCGP
• Innovate podcast: Resilience in Primary Care podcast—RCGP, May 2020
• PPE for the mind—RCGP wellbeing course/webinar
• First You: Caring for those who care for us—A hand-picked collection of wellbeing resources for healthcare workers.
• Counselling and peer support for doctors and medical students—British Medical Association.
• Worried you may be burning out, drinking too much or nicotine dependent?—British Medical Association.
• British Medical Association self-assessment questionnaires:
  • Nicotine dependence
  • Burnout
  • Alcohol
• Am I an addict?—Narcotics Anonymous.
• A free tool that reminds you to take regular breaks—regularbreaks.com
• Be kind to your mind—Headspace.

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