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Adversity, resilience and persistence.

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Physician leadership often has to deal with adversity, but resilience and balanced persistence can help ensure improved outcomes--for you, other individuals, organizations and society.

I ENJOY ENDURANCE SPORTS AND SPENDING time outdoors in difficult environments. The day before writing this column, for example, I was out running in the woods on muddy, puddle-laden trails in pouring rain.

Part way through, I tripped, fell into a pool of murky water and emerged completely covered in black ooze. After realizing I had no injury, I laughed at the situation for what I must have looked like and then carried on to complete what turned out to be a great run. I enjoyed it!

This was not the first time I tripped on the trails, nor will it be the last. But why do I persist?

Certainly I enjoy the physical benefits of lifelong fitness, but I also find that I relish that sense of accomplishment when something complex has been achieved. For me, it is often less about the journey and more about the result. Do not get me wrong here, though--although the results give me greater pleasure, the journey in these settings can also be deeply satisfying despite arduous and difficult circumstances.

Over time, I have benefited greatly by having my capabilities challenged by managing the difficulties of a journey and by learning to continually improve my approaches (mostly psychological). Those capabilities have improved because of my recognition that, when properly channeled, adversity inevitably will result in improved resilience. This, in turn, enables me with an improved ability to persist as I strive to reach my goals.

ADVERSITY--The Merriam-Webster dictionary definition of adversity (noun) is: a difficult situation or condition; a misfortune or tragedy.

"The most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have an appreciation, a sensitivity, and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen."

--Elizabeth Kubler-Ross

Being physician leaders, we routinely face adversity--both professional and personal. We see numerous clinical examples daily, and we also see frequent examples of ways to manage it. The core nature of who we are as physicians, how we were trained and how we practice our skills, helps provide us with the resilience to weather adversity.

RESILIENCE--The Merriam-Webster dictionary definition of resilience (noun) is: able to become strong, healthy or successful again after something bad happens.

"Resilient people do not let adversity define them. They find resilience by moving towards a goal beyond themselves, transcending pain and grief by perceiving bad times as a temporary state of affairs. ... It's possible to strengthen your inner self and your belief in yourself, to define yourself as capable and competent. It's possible to fortify your psyche. It's possible to develop a sense of mastery."

--Hara Estroff Marano, Editor-at-Large for Psychology Today

Our long years of medical education require resilience! And then, our persistence through that education prepares us to launch into a career trajectory that also requires ongoing resilience and persistence. Likely, most of us did not even recognize that we started to develop these critically important capabilities early in our careers. Turns out, it is a prescient set of skills.

As the health care industry continues to gain complexity and evolve at an ever-increasing pace, it is now almost imperative that if we do not already have natural resiliency, then we should each seek ways to gain it.

Almost all the adversities we witness in health care will continue in some fashion and our need for persistence endures. Nonetheless, it is our personal resilience that will allow us to manage adversity better and use persistence to achieve better results.

PERSISTENCE--The Merriam-Webster dictionary definition of persistence (noun) is: the quality that allows someone to continue doing something or trying to do something even though it is difficult or opposed by other people.

During World War II, well before my time, Winston Churchill tried to lift the spirits of the British people through an analogy for persistence. Knowing their ongoing fight with Germany was difficult, he painted the picture by saying, "The nose of the bulldog has been slanted backward so he can breathe without letting go (of his adversary)."

From what I understand, this was a well-accepted and highly motivational moment for the British public and the armed forces.

While writing this column, I also came across a clinically relevant article that provided deeper insight into the thinking of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Medication Compliance and Persistence Work Group--a group that developed clinical definitions for compliance and persistence during three years of international review and discussion.

"Clinical outcomes of treatment are affected not only by how well patients take their medications, but also by how long they take their medications. Thus, compliance and persistence should be defined and measured separately to characterize medication-taking behavior comprehensively. Addressing both compliance and persistence provides a richer understanding of medication-taking behavior." (1)

I found this latter nuance intriguing and it has placed the simple act of patient engagement in a much clearer context for me, personally. Certainly, our patients require resilience for general health approaches and in all types of treatment strategies for illness.

For them, these represent adversity and they will each make personal choices on their eventual compliance with the recommended approaches. But, regardless, persistence is always needed because that is the nature of illness and disease--adverse situations usually do not just go away. Positive or negative results will prevail, depending on the success of the treatment.

As physician leaders, we have to continually develop these complex skills of resilience and persistence; not only as individuals, but also for our patients and the organizations in which we work. All physicians are viewed as leaders at some level, and often the presumption is that innately we already have the ability to manage adversity effectively.

That is not always the case and it underscores my point on the need for each of us to consider how to evaluate our existing degree of resilience and how to expand it. Our persistence in improving resilience will not only provide a better end result for our patients and our organizations, but also will benefit ourselves, our families and our circle of friends.

The interview we feature with Dr. Bennet Omalu in this issue of the PLJ, and also found on our website (, is an intriguing story of exceptional success in taking on adversity with resilience and persistence. His early efforts in the past dozen years to define chronic traumatic encephalopathy (CTE) in National Football League (NFL) players are continuing to be felt within professional sports around the globe.

In addition, it is just beginning to be recognized within the general public and dramatically changing the nature of organized amateur sports. For me, his story is not just about the NFL, but is one of scientific integrity that carries profound public health ramifications. By demonstrating personal resilience and effective persistence, Omalu overcame significant adversity to create a highly important end result for society. It is an interview with one of our association's CPE graduates worth reading.

Physician leaders can learn a lot from stories about overcoming adversity. Physicians also can learn significantly from those highly motivated individuals we come across in the clinical delivery system--patients and providers.

We can all work toward creating large-scale change for health care by demonstrating resilience and persistence when it comes to improving the outcomes of patient care, and the outcomes for higher quality, safe, efficient systems of care. Our society benefits from the focus and skills of physicians when they serve as leaders.

It is my core altruism and my personal commitment to physician leadership that helps drive me to improve my own resilience. I do this by seeking a variety of challenges, which represent adversity, and they help me grow through my persistence. So if you see a muddy-looking trail runner approach, please don't turn away--laugh with him and let him know you appreciate what is going on under his mud-covered clothing. I encourage you to find your own version of the muddy trails and enjoy what it brings to your ongoing personal growth.

All physicians can be considered leaders. So get more engaged, stay engaged and help others to become engaged. Creating a broader level of positive change in health care--and society--is within your reach.



(1.) Cramer, J.A., and others. Medication Compliance and Persistence:Terminology and Definitions workpaper/research_practices/Cramer.pdf (Accessed 2/12/2016).

Peter B. Angood, MD

President and CEO, American Association for Physician Leadership[R]
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Title Annotation:From the CEO
Author:Angood, Peter B.
Publication:Physician Leadership Journal
Geographic Code:1USA
Date:Mar 1, 2016
Previous Article:Surgeon: a haiku.
Next Article:Meet Bennet Omalu, MD: the physician leader whose research inspired the movie concussion.

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