SUO 2019: Resilience: The Art of Failing Forward

Washington, DC ( At the Young Urologic Oncologist’s program, Dr. Sasha Shillcutt, an anesthesiologist, provided tips for resiliency and the art of "failing forward." Dr. Shillcutt notes that all specialties are feeling the effects of burnout. According to a 2017 survey, the most affected specialty is emergency medicine, with nearly 60% of emergency department physicians feeling the effects of burnout, which is up from 50% in 2013.1 Urology ranked 9th, with more than 50% of urologists feel burned out (stable between 2013 and 2017); both General Surgery (current 50% burnout rate) and Anesthesiology (52%) had significant increases in burnout between 2013 and 2017.  
Burnout has a lasting impact: 20% of physicians experience mental health problems over their career, which has also lead to a 2.3x increased suicide rate (women 2.3x risk; men 1.6x risk). In a survey of 7,288 physicians, compared to 3,442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%; p < 0.001) and to be dissatisfied with work-life balance (40.2% vs 23.2%; p < 0.001).2 Compared with high school graduates, individuals with an MD/DO degree were at increased risk for burnout (OR 1.36; p < 0.001), whereas individuals with a bachelor's degree (OR 0.80; p = 0.048), master's degree (OR 0.71, p = 0.01), or professional or doctoral degree (other than an MD/DO) (OR 0.64; p = 0.04) were at lower risk for burnout. According to Dr. Shillcutt, the most common pathway that leads to burnout starts with empathy loss (highest as a first-year attending), as well as increased stress (secondary to a low level of work control, acuity of patients, and work compression), eventually leading to burnout. Burnout leads to exhaustion, cynicism, disengagement, and inefficiency.   
Scarily, burnout has also been shown to lead to medical errors among surgeons. In a study from 2010 among 7,905 surgeons, 700 (8.9%) reported a major medical error in the previous 3 months, and >70% of surgeons attributed the error to individual factors.3 Furthermore, reporting an error had a large, statistically significant adverse relationship with mental quality of life: each one point increase in depersonalization was associated with an 11% increase in the likelihood of an error. Burnout and depression remained independent predictors of reporting a major error on multivariate analysis (controlled for other personal and professional factors, such as being on-call, etc).  
 Although stress and burnout may be closely related, there are several important differences: 

 SUO 2019 failing forward burnout
Dr. Shillcutt notes that to “be” resilient, you must “do” failure. Accepting defeat is the neuroscience of screwing up: we must check our assumptions, seek out the ignorant, encourage diversity, and beware of failure blindness.  
 Resilience is defined as: 
  • Bouncing back 
  • Toughness 
  • Positivity 
  • Mental stability 
  • Self-esteem 
  • Self-respect 
 What resilience is not: 

  • Ideologic existence  
  • Unaffected by trials 
  • Never experiencing professional failure 
  • Untouched by stress or hardships 
  • Painless 
Several studies have identified how we can “fail forward” and build resiliency. A German study conducted 200 semi-structured interviews with physicians across different ages, disciplines and hierarchical status4 to identify health-promoting strategies in order to define prototypical resilience processes. Analysis of this qualitative data, suggested three important dimensions: (i) Job-related gratifications derived from treatment interactions; (ii) Practices. For example, leisure-time activities, self-demarcation, limitation of working hours, and continuous professional development; (iii) Attitudes. For example, acceptance of professional and personal boundaries, a focus on positive aspects of work, and personal reflexivity. The authors concluded that enriching traditional stress management approaches with the dynamic of positive as well as negative resource spirals would appear to be a promising approach to building resiliency. Researchers from the Mayo Clinic developed the “Listen-Act-Develop” model, an integrated strategy to reduce burnout and engage physicians in the mission of the organization.5 The intent of the model is to maximize physician wellness by fostering engagement and mitigating the drivers of burnout. This model provides a path to increase physician satisfaction and meaning in work and to improve organizational effectiveness. Key components of building resilience according to the book “Building Resilience for Success” include confidence, social support, adaptability, and purposefulness.  
It is important to remember that resilient people experience failure, experience loss, experience stress, and feel the pain of loss just as much as non-resilient people. When we fail, it is important to look for the lesson in failure, be vulnerable and share our feelings with others, do an internal check, own our strengths, and create a plan to mitigate future failure.

Presented by: Sasha K. Shillcutt, MD, Nebraska Medicine, Omaha, Nebraska

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md, at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC   

1. Parks T. American Medical Association. Report reveals severity of burnout by specialty. Available at:
2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172(18):1377-1385.
3. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and Medical Errors Among American Surgeons. Ann Surg 2010;251:995-1000.
4. Zwack J, Schweitzer J. If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med 2013;88(3):382-389.
5. Swensen S, Kabcenell A, Shanafelt T. Physician-Organization Collaboration Reduces Physician Burnout and Promotes Engagement: The Mayo Clinic Experience. J Healthc Manag 2016;61(2):105-127.