Resilience and Sub-optimal Social Determinants of Health

Abstract

The relationship between social determinants of health (SDOH) and resilience has been investigated at the individual level and, to some extent, at the community level. The aftermath of the COVID-19 pandemic further highlighted the necessity for organizational resilience in the United States. The US public health and health care system began the lengthy process of identifying the resiliency needs of its workforce that expand beyond disaster preparedness. The purpose of this article is to describe the relationship between resilience and SDOH and how medical training can infuse resiliency within the curriculum and clinical practice.

Key points

• •The aftermath of the COVID-19 pandemic highlighted the necessity for organizational resilience in health care.
• •Distinguishing resilience from well-being and self-care can elevate individual and community resiliency building as an essential tool for improving the outcomes of the healthcare workforce.
• •We suggest building resilience through medical training and reviewing current curriculum and clinical practice.

Defining resiliency

Resilience, described as a process than a personal characteristic or trait, is the ability to adapt and thrive despite adversity.¹ Scholars explain that resilience is "the negotiation, management and adaptation to significant stress and/or trauma”.^{2 , 3} Research on resilience typically focuses on the environment or the individual and originates in the fields of ecology and psychology. In ecology, resilience is defined as “a measure of how much disturbance an ecosystem can endure without shifting to a different state”.⁴ In the early years of psychology, resilience was observed via longitudinal studies and focused on identifying protective and at-risk factors that either benefited or hindered individual growth.⁴ In this article, we describe the relationship between resilience and social determinants of health (SDOH) and how medical training can infuse resiliency within the curriculum and clinical practice. We will use the case study of Jessica¹ to illustrate the ways in which resilience can manifest at the individual level as well as community and organizational opportunities to foster resilience.

The Case of Jessica

Jessica was 9 when she was diagnosed with acute lymphoblastic leukemia. She lived in a rural area without access to a hospital, so she traveled 90 minutes away from her family home for treatment. Jessica experienced many of the complications that can arise from chemotherapy, and she spent many weeks in the hospital while receiving chemotherapy and being treated for complications from the chemotherapy. Jessica’s parents worked to afford health insurance, so she spent many hours alone or with her grandmother while receiving treatment. Jessica’s community rallied around her parents during treatment and provided funds for travel and time off of work. In addition, several people from the community volunteered to care for the family home, doing yard work and caring for the pets, so Jessica’s parents could be with her during treatment as much as possible when they were off of work.

Jessica enjoyed being in the hospital when she thought well enough to play and interact with the staff, nurses, and doctors. She asked a lot of questions, proved to be a quick learner, and was encouraged to think about a career in medicine when she grew older. After 2 years of arduous treatment, Jessica was in remission, and started routine posttreatment care. As a middle schooler, Jessica excelled in school, told everyone she was going to be a doctor, and joined 4-H to improve her communication and skill set to help her get ready for college. No one in her family had ever been to college, and she only knew that colleges liked to see community involvement and extracurricular activities on applications.

Jessica graduated at the top of her class in high school, attended state college on loans and scholarships, and worked hard to get into medical school. Her MCAT scores were lower than hoped for, and she was denied admission the first time she applied. After college graduation, she returned to her hometown, took a job in a local pharmacy as a pharmacy technician, and resumed studying for the MCAT. Her second application cycle was successful, and she was admitted to the state medical school several hours away from her family.

Jessica performed well in medical school and matched into her top choice family medicine program in another state. While in residency, her father died after a short illness with brain cancer. Her residency program did not reach out or help her during her father’s illness or death. In addition, she missed too much time away from the program while caring for her father at the end of his life to finish on cycle. Jessica became depressed, disillusioned with medical training and angry at herself that she had traveled so far from her hometown to train, thus leaving her mother to cope with her father’s death alone. During her grief and disappointment, her romantic partner of several years ended their engagement. Because of her difficulties with worsening sleep, mood, and functioning, Jessica fell behind in documenting her medical records, was late to rounds and clinic several times, and was judged to have demonstrated “insubordination” to her program director. She was placed on probational status and advised to enter therapy, which she did, but found it minimally beneficial.

Despite these setbacks, Jessica successfully finished her training program and entered practice in community health back in her home state. She established new colleagues and friends, found a romantic partner, married, and had 2 children. Jessica worked hard to establish a wide net of support so she would not think the isolation and loss of hope she had thought during her medical training. She worked hard to establish good practice habits to ensure she kept in control of her medical records and established a good record of professional and cordial conduct.

Jessica, seeing her own journey through many difficulties, thought empowered to do what she had always longed to do, open her own medical practice. She found the right space, rehabilitated the space to create a warm and welcoming environment, hired an exceptional business manager, and opened her own practice with a clearly defined goal of caring for her community while making a living to help support her family. She used creative marketing and good business practices to grow her practice, hired additional support staff and an additional physician. A medical student who spent their family medicine clerkship with Jessica recently wrote her a thank you note expressing their admiration for “how easy you make it all look.” Jessica had to chuckle. None of it had been easy, most of it had been difficult, but she recognized she had stuck with it, set realistic goals, and learned to thrive.

Leveraging the Community to Foster Resilience

Research on SDOH posits that the community people live in affects their overall health and well-being. The World Health Organization defines SDOH as “the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life”.⁵ Relatedly, community resilience is defined as the ability of a collective group of people to work together to overcome common adversity that affects people who live and work together. A related concept, collective efficacy, is defined as the mutual trust and willingness to intervene for the common good of the greater community.⁶ Sampson postulated that when communities have trust with their neighbors, they are able to leverage support and resources that act as a protective factor for the community during times of adversity. In Jessica’s case, when she was battling cancer, her family garnered support from their community. Neighbors offered to help care for their home and pets in their absence. They also provided financial assistance for the needs of the family. Collective efficacy is evident in the community assistance Jessica’s family received during her years of treatment. The community’s willingness, ability, and responsiveness to Jessica and her family contributed to Jessica’s individual level of resilience as well as the community’s resilience.

Similarly, research investigating the environmental factors associated with SDOH that either reinforce or diminish resilience focuses on 4 key attributes: (1) inclusion, (2) social conditions, (3) access, and (4) involvement.⁷ Inclusion embraces, accepts, and makes room for all genders, races, ethnicities, ages, cultures, and identities. Creating inclusive environments promotes a sense of belonging, equity, and fairness, and removes social barriers.⁷ Inclusion as an environmental factor bolsters resilience. Inclusion is exemplified in Jessica’s case by how she was treated by the clinical staff when she was receiving chemotherapy. The staff, nurses, and doctors entertained her inquisitiveness, answered her questions, and encouraged her to pursue a career in medicine, thus making her think a part of the team. Jessica carried these experiences with her throughout primary and secondary school.

The second factor, social conditions, relates to socioeconomic factors that directly contribute to SDOH.⁵ Social conditions include having adequate and safe housing, equitable education, and appropriate medical coverage.⁷ Both of Jessica’s parents worked full-time jobs to ensure she had the medical coverage needed to pay for her chemotherapy. Having to work long hours resulted in Jessica being alone often or in the care of her grandmother while in the hospital. Social factors such as having appropriate medical coverage play a significant role in resilience and directly affect mental health, which is a key resource in developing resiliency.

Access is the third environmental factor attributed to resilience. Access includes the ability and resources to draw upon the health, education, and civic systems in ways that are beneficial to the individual and community. For Jessica’s family, the nearest hospital that offered the treatment she required was 90 miles away from her home. The distance created significant hardship for her family to ensure she received proper care. The closure of several hospitals in rural communities in recent years has contributed to reduced access to care and health equity.⁸ Health care facilities that are strategically placed for accessibility, and responsive civic systems that work together to provide residents with quality care enhance community resilience.

The final environmental factor affecting resilience is involvement. Involvement differs from inclusion in that involvement requires action on the part of the individual, whereas inclusion creates social space for all people. Active involvement not only builds self-confidence, but it also helps to expand one’s community and social connections and contributes to collective efficacy. In Jessica’s adult years, she sought to build her social network in a way that provided the necessary support to her during difficult times. Her proactive approach to involvement mediated the poor mental health and isolation she thought during her residency and reinforced a sense of belonging, all of which support resiliency. Jessica fostered community and through her social network, contributed to community resilience. The case study illustrates how each of the environmental factors is interconnected and follows a social gradient fashioned along socioeconomic inequity.

COVID-19 Unearths Lack of Organizational Resilience

Much of the literature on resilience focuses on the individual’s ability to activate resilience, which has been touted as an answer to many social ills. Although this is an important approach, individual-level efforts should not be the primary focus for developing resilience. The concepts of community resilience can be scaled up and applied to organizations, particularly in the health care system.

Following the COVID-19 pandemic, the US public health system began the lengthy process of identifying the resiliency needs of its workforce that expand beyond disaster preparedness to consider ways to bolster workforce resilience. What is evident from the strain placed on the health care system and the clinical staff during the pandemic is the woeful conditions in which hospitals and health care facilities offered mental health care and support to their clinicians and staff.⁹ The medical profession has important decisions to make to not only stay current with contemporary workforce support observed in peer countries but to also provide the necessary support for an industry facing serious and possibly catastrophic staffing shortages.^{10 , 11} Medical schools have a duty to prepare their students with the clinical tools to offer optimal care. Where training wanes is in assisting trainees to develop the resilience skills needed to provide proper care to their patients while simultaneously caring for their own well-being.¹²

Medical Student and Resident Physician Wellness and Resiliency

Over the last several decades, the need to improve the well-being of medical students, residents, and practicing physicians has been recognized. The recent emphasis on student and resident trainee wellness in curriculum and training is due to several decades of surveys of medical students and residents demonstrating that trainees often experience a decline in their mental health throughout training, including higher incidents of anxiety, depression, burnout, self-harm, and suicidality than their same-aged peers.^{13 , 14}

Both credentialing bodies that set the curriculum content standards, the Liaison Committee on Medical Education (LCME) for medical school and the Accreditation Council for Graduate Medical Education (ACGME) for residency, require a curriculum on wellness and mental health to address these concerns. In addition, the LCME and ACGME have standards on workload and fairness of evaluations and feedback to ensure trainees have access to clear practices and processes and leave time for personal wellness (LCME standard 8.8 and ACGME Common Program Requirements VI.C). Although it is still being determined if workload limits and required education on wellness and mental health improve student and resident outcomes, the benefits of meeting the accreditation standards may be washed out by many other factors. Other factors include the lack of workplace autonomy, financial strain due to poor compensation, student loan burden, and experiencing what some refer to as the "moral injury" of caring for patients in a health care system poorly equipped to support health care workers and their care for patients.

One common theme of well-being is having (being given or making) time for self-care. Resilience is mentioned as naturally flowing from self-care, as if there is a bank of resiliency, and the way to fill it is with self-care. In many trainings for students, residents, and practicing physicians, there is little recognition of resilience as the potential everyone brings from their lived experience is specific to an individual's life and circumstances and is built upon intentional practice rather than self-care. Emphasizing resilience is not to devalue self-care, which can be used to improve a sense of well-being. Self-care can include time away from work, pursuing outside interests and hobbies, sleep, rest, and rejuvenation through recreation. However, a distinction should be made between self-care and resilience. Self-care and well-being are not always assessable due to difficult circumstances beyond our control (eg, a health crisis, natural disasters, pandemics, and the loss of loved ones). In addition, self-care usually requires resources that include time, money, energy, and agency.

In contrast, resilience can be fostered and built with readily available resources. For example, in the above case study, Jessica was expected to return to a demanding residency program after her father's death, and there was no time for "self-care." However, what could have changed Jessica's residency outcome, and avoided the disciplinary action that placed Jessica and her career in medicine in a precarious position, was support from her program and colleagues, thus potentially bolstering Jessica's resilience and helping her overcome her professional and personal setbacks. One brief meeting with the program director after Jessica returned from her bereavement could have identified what support Jessica needed to return to her program successfully. Jessica describes this residency experience as "ostracizing and highly traumatic." Moreover, although she wishes she had never experienced the setback, she recognizes it as giving her extraordinary empathy for patients who struggle to perform (work, school, and family life) in adverse environments because of not having the community and family support that would make the difference between setbacks and successful navigation of difficulties.

In addition, distinguishing resilience from well-being and self-care can elevate individual and community resilience building as an essential tool for improving the outcomes of the health care workforce and the patients they care for. Teaching health care workers to recognize their resilience and the resilience of their patients and communities emphasizes existing and potentially emerging strengths. These strengths are the foundation for growth than depending on individual self-care banks that are filled and quickly depleted.

System Change and Improving Workplace Culture to Address Wellness and Resiliency

Mental health and wellness curricula differ across training programs, but in general, they center around reminding trainees about good habits to stay mentally healthy with self-care and how to seek help if mental health or problem behaviors become a barrier to success for the trainee, especially as it relates to their functioning in school or residency. Well-being is a complex phenomenon, and there is yet to be strong evidence that the current curricula improve student and resident well-being. Currently, the studies exploring curricula effectiveness often look at short-term measures, have fewer participants, and have limited follow-up. In addition, the curricular interventions vary widely between schools and programs, making comparisons and conclusions elusive.¹⁵ The ACGME wellness program brings workplace culture and systemic changes to training to the forefront as potentially meaningful ways to improve wellness in trainees. Similarly, the LCME emphasizes stringent attention to clear and enforced policies, such as duty hours policies and policies guiding adequate independent study time, to promote improved medical education environments with sufficient time for study and engagement in self-care. This emphasis on systemic changes as important foundational aspects of individual and workforce wellness is an encouraging sign that the superficial emphasis on an individual's path to wellness (often with “token” offers such as chair massages, meditation sessions, lunch break yoga, and “surprise” gifts of desserts) will diminish because calls for systemic changes become more unified.

Despite the efforts of the LCME and individual medical school wellness programs, some survey data suggest that student wellness, defined as “having eight dimensions: intellectual, emotional, physical, social, occupational, financial, environmental, and spiritual"¹⁶ has declined recently. The COVID-19 pandemic and the social isolation this might have caused, more significant societal upheaval, friend and family poor health and death, increased patient needs and demands, and even poor enforcement of work hour limits are potential contributors to this decline. Meanwhile, schools and training programs are revisiting their wellness curricula to combat the rising numbers of trainees with depression, anxiety, and other mental health concerns. Addressing resiliency awareness and training is an emerging theme to reinvigorate wellness programs, including the AAMC (Association of American Medical Colleges) program.

Adding resilience awareness and training among medical trainees is a solid step that will allow individuals to build their skills and understanding, improve their outcomes, and share and promote these skills with their patients. However, again, the caution is to ensure this training is coupled with empowering trainees to advocate for changes that further increase individual and institutional resiliency. Returning to Jessica and her difficulty in residency, it is important to revisit that it would be minimally helpful to encourage Jessica to be resilient in the face of her father’s death as the residency program was unwilling to think carefully about supporting their resident and colleague through a challenging time in her life. Resiliency curricula could be offensive to students and trainees if they do not include how these individuals will be supported by resilient communities and institutions. Just as teaching patients how to recognize and use their resilience is not to replace advocating and replacing systems of oppression and dehumanizing policies and cultural practices, teaching medical trainees the same skills is not a substitute for pressing for policies that result in improving the environment and culture of medical education and residency training.

Impacting Patient Outcomes by Screening for Resiliency in Patients with Less-Than-Optimal Social Determinants of Health

As students, residents, physicians, and others on the health care team learn and intentionally enhance their individual, community, and organizational resiliency, a natural extension is to ensure patient care is placed in the context of understanding the patient in terms of individual and community resiliency. In the past, primary care physicians were trained to focus on the medical problem lists and note SDOH as contributors to poor health outcomes and part of the social history. Primary care evidence-based preventive health screenings improve patient outcomes.¹⁷ However, SDOH often becomes the most significant predictor of overall patient quality of life and longevity.¹⁸ Health care workers are usually only in the position of mitigating SDOH by treating the results of chronic diseases and managing these diseases' ravages on well-being, function, and longevity. In communities with less than optimal SDOH, community and societal change would have a much more significant impact on overall health and longevity than the individual treatment choices a provider makes about an individual patient's resulting chronic health problems. However, positive social and community changes are usually incremental at best. Advocating for change and effective policy for a broader impact is separate from most primary care physicians' training.

Primary care physicians have the opportunity to deliver additional impact by helping their patients identify personal characteristics and lived histories that can contribute to resiliency. Brief assessments and interventions can help the physician and the patient better understand the facilitators of resiliency and identify community measures that can contribute to resilience. For example, Jessica, given her family's history of needing help during her illness and recovery, recognizes how important extended family, community, and local resources are to her patient and the patient's family when she diagnoses her new patient with multiple myeloma. The integration of primary care and behavioral health care in clinical settings is one example of the medical field's role in bolstering patient resiliency. Medical social workers providing support beyond medical needs in pediatric units, maternal care wards, and family medicine play an essential role in delivering comprehensive patient-centered care.

Most of the recommendations for screening and patient education in primary care revolve around the search for previously undiagnosed disease states (eg, screening tools for major depressive disorder, type 2 diabetes, and hyperlipidemia), with the hope that diagnosing these conditions early will mitigate the impact of these conditions. As many providers who work in communities with less than optimal SDOH can attest, the screening and diagnosis of diseases made more frequent and deadlier by high levels of poverty and other societal ills can be akin to putting out a raging fire by ladling small spoons of water on the flames. The bigger problem is the societal, political, and cultural harms that light the match and add the accelerator to the causative factors of these chronic disease states.¹⁹ Screening for SDOH that can improve the quality of life and longevity could be a step toward more rational screening for communities with less than optimal SDOH. Screening and offering interventions for building resilience can improve patient health and well-being, which can reduce the disease burden of communities with less than optimal SDOH. Despite being weary of the demands of mandated screenings and incremental chronic disease management, primary care physicians who embrace a tool meant to "flip the script" to screening for prior adaptations made by the patient during times of adversity can be built upon to mitigate disease progression and poor outcomes.

Providers who follow screening guidelines often use screening tools embedded in the electronic health record, and completing the screening is then used to assess the quality of care patients receive. When available in resource-strained systems, medical teams, including para-nursing staff (medical assistants and noncertified or licensed health care staff), nurses, social workers, and others, ensure the recommended screening is performed. Given the evidence for the positive impact building resiliency can have on mitigating, avoiding, and getting through future adversity, adding a validated resiliency screening tool to patient populations with less-than-optimal SDOH will help identify patients who need further assessment and referral to resiliency-building training and interventions. As with other screening tools, this could be performed by the members of the nonphysician medical team, thereby not adding undue burden to the overall cost or time of the medical encounter.

Screening patients for their ability to adapt to adversity will also place this factor in its proper place as a significant contributor to well-being and longevity. Funding, developing, and supporting resiliency-building interventions for patients and communities who need them the most is essential work, providing the framework for the necessary step beyond screening. The health coaching model already uses patient empowerment and recognition of strengths to build a patient-centered and patient-derived plan for improving outcomes. Health coaching skills, including resiliency screening and building, ideally taught early in the medical career, can be reinforced throughout training in simulated patient experiences, case-based learning, and clerkship experiences so that the recognition and building of a patient's resiliency become an assessed portion of the patient interaction while in training. Many practicing physicians already offer brief interventions based on the health coaching model (eg, tobacco cessation). These interventions can be billed for and reimbursed, especially in models that pay for high-value care.

Summary

The development of resilience skills is necessary not only for the benefit of medical students and residents but also for the benefit of their patients. The organizational position on resilience has a profound impact on standard operating procedures in the practices of its clinical staff as well as in the way it provides care to its patients.

Given the aftermath of the COVID pandemic and the impact it had on clinical personnel and patients seeking care, the medical profession can seize the moment and bolster the overall wellbeing of its workforce. The World Health Organization issued several organizational recommendations to better support health care workers. Some recommendations include ensuring staffing levels that are appropriate for the flow of patients, allocating equitable workloads, providing breaks and time off between shifts, supportive supervision, and paid leave off.¹²

In addition to organizational support, there is a need for a systematic shift that prioritizes the health and well-being of health professionals. International health organizations posit that “it is the mandated obligation to protect workers through the prevention of harmful physical or mental stress due to conditions of work and to recognize the right of everyone to a world of work free from violence and harassment, including gender-based violence and harassment.”¹² The WHO further suggests that it is the duty of the overall health care system to prevent harm from the dangers and hazards of its workforce by providing mental health support and protection from violence, including workplace bullying. The health care system needs to provide support with fair and equitable compensation and social protection, promote inclusivity and belonging in a safe work environment free from discriminatory practices, and finally safeguard workers’ rights to collective bargaining and ensure an environment free from retaliation.

Clinics care points

• •Addressing resiliency awareness and training is an emerging theme to reinvigorate wellness programs, including the AAMC program.
• •When adding resilience awareness to medical training, ensure this training is coupled with empowering trainees to advocate for changes that further increase individual and institutional resiliency.
• •When working with patients, trainees should screen for SDOH that can improve quality of life and longevity.
• •Screening and offering interventions for building resilience can improve patient health and well-being, which can reduce the disease burden of communities with less than optimal SDOH.

Disclosure

The authors have nothing to disclose.