DRAFT WORKING DOCUMENT
Resilience Curriculum
( updated August 2013 )
The Practice Resilience Theme will average 34 hours over the course of the four year Geisel
curriculum. It will engage students in evidence-based skills-building using a variety of
pedagogical methods designed to be inspiring, practical and generalizable to settings both
within and outside of medical school. Sessions will be interwoven into the Foundations of
Medicine and the Core Biomedical Curricula, and at strategic points in the clinical years.
These sessions will address the neuro-physiological underpinnings of stress in pragmatic,
“experience-near” terms, as well as its impact on patients, providers, quality of care and clinical
decision making. Emphasis will be on practical acquisition and enhancement of Resilience skills
(“tools”) which will improve patient outcomes, student performance, satisfaction and self-care,
while reducing the impact of stress that is inevitable in life- long medical practice. Sessions will
align with the Ethics and Humanities Themes and will be positioned to provide inoculation
against predictable stress points in the curriculum. We propose to use Kern’s (2009) iterative
framework for medical school curricular design as outlined below.
~Problem Identification: Burnout
Burnout is associated with professional and personal undesirable outcomes. Resilience, an
antonym of burnout, is associated with desirable outcomes. We have adopted the following
common definition of Resilience: “Resilience is the capacity to adapt successfully in the
presence of risk and adversity.”
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Outcomes related to Burnout:
Professionalism declines: Students with burnout are 11 times more likely to say they
ordered a test on a patient when they had not and over 2 times more likely to cheat on
an exam.
Empathy and altruism decline: Students with burnout are half as likely to agree with the
following statement compared to peers: “Medical student should be concerned with
the problems facing the underserved”.
Burnout threatens regional and national efforts to recruit and produce a work force
that will provide care to underserved populations. This appears to be related to all of
the burnout subscales: cynicism, exhaustion, and self-efficacy.
Patterns of reaction to the unavoidable stressors of medical school, including burnout,
have a continuum of serious consequences and become “learned behaviors” in the lives
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of practicing physicians. These patterns directly affect patient safety as well as patient
and provider satisfaction.
Practicing physicians with Burnout have:
o High rates of job dissatisfaction.
o Elevated rates of suicide, missed work time, and substance abuse.
o Declines in empathy and professionalism resulting in profound negative effects
on the doctor-patient relationship.
o Poor patient care and satisfaction ratings.
o Statistically increased medical error rates.
Practicing physicians with Resilience have:
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Increased career satisfaction.
Higher personal life satisfaction.
Enhanced performance and efficacy.
Engagement with lifelong learning.
Skills that may be modeled and directly transferable to patients (e.g., CBT).
~Targeted Needs Assessment
Geisel students have significant Burnout as documented by an in-house longitudinal study.
Geisel students showed marked early and prolonged increases in all subscales of the Maslach
Burnout Inventory, the most widely used, well- validated instrument to assess professional
Burnout. These findings resulted in choosing the Promotion of Student Wellbeing as a core
component of Curricular Redesign.
~Goals and Objectives
Practice Resilience skills will map on to Core Competencies
General goals: To ensure that the re-designed curriculum promotes a life-long energized
engagement in medicine and a healthy balance in personal and professional life; and, to
minimize factors stifling personal growth and active learning through life, all of which are
intrinsic to Professionalism.
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Prepare students to anticipate, address and learn from the unavoidable stresses of a
career in medicine, i.e. to adaptively persist when stressed.
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Prepare students to build upon the joys and challenges of caring for patients and
communities with integrity and compassion.
 Emphasize both within and outside of the curriculum the importance of personal
wellbeing and the development of practice resilience.
Competencies most directly related to Resilience under development ( Version below is from
August 2013; not approved final version!)
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Engage in active learning in the pursuit of the expertise, awareness, and resilience
necessary to enhance one's effectiveness .
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Develop learning approaches and resilience that will facilitate lifelong acquisition of knowledge,
self-awareness, professional effectiveness and satisfaction.
~Strategies
Evidenced-based and research-informed Resilience factors will be mapped to various
operational “levels”. These levels include individual, community, family, and organizational.
This framework of levels helps partially separate and target the Resilience factors that are
intrinsic to the individual versus those that involve others who constitute the larger group (e.g.,
Geisel, local community, or family). The individual “ level” is the primary target of the
resilience curriculum supported by the organizational and family/community “levels”.
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Faculty development and Geisel leadership will focus on the organizational
culture “level”, i.e., the learning environment, although hierarchical culture will
be addressed in the Resilience and Ethics curricular threads.
Faculty development will also facilitate support the resilience curricular content
which will emphasize entrainment and enhancement of individual Resilience
factors.
The mentoring and advising structure will focus on the family and
community levels.
Does Resilience education work? Resilience education has been heartily embraced by nonmedical professional educators whose students are exposed to abrupt changes in culture
and environment. The US military is utilizing a Resilience curriculum developed at Penn’s
Institute for Positive Psychology in their basic training for battlefield platoon level
commanders with encouraging results. Although being in a war zone involves profound
stress, medical school and the immersion into medicine presents its own set of profound
environmental changes and stressors on learners.
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The military has done an extensive literature review identifying 20 Resilience factors, 11 of
which are substantiated by RCT’s. There is a paucity of literature on Resilience interventions
in medical learners compared to other academic learners. One study reports that a short
Stress Management and Resiliency Training (SMART) intervention in practicing internists
had very positive short-term outcome effects using the Connor-Davis Resilience scale and
QOL surveys. Likewise, training with cognitive behavioral therapy skills has demonstrated
positive effects with medical students.
Resilience content, based on the RAND report’s evidence-based, research informed factors will
be mapped to the competencies. Curricular content will be fit into the following arenas with
strong emphasis on” buy-in” and applicability to student performance and their future patient’s
wellbeing as incentives for learning.
1. Experience of others indicates that reasons for buy-in may vary across stages of
learning. In preclinical years performance enhancement incentivizes buy-in,
whereas in the early clinical phase it is patient outcomes, and for practicing
physician’s life balance issues appear to be particularly relevant. A sound
scientific foundation—the rationale-- of teaching strategies for Resilience is
critical to get “buy in” during medical school.
2. Life strategies: productivity, sleep, preventive health, self-care, balance.
3. Engagement in the process of learning over time with focus on learning as a
continuous process versus a static “mastery of content” end-point.
4. Neurobiology, neuropsychology, and physiology of stress and strategies or
“Tools” to prevent and actively cope with stress, using Biofeedback, CBT for
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self- and patient-care, and Mindfulness inside and outside of medical practice.
~Methods
Pedagogy will involve formal lectures/small group learning, self-directed learning,
experiential exercises, probable Personal improvement project related to resilience topic, and
“stealth” applications of principles reinforced in real time during clinical rotations.
Techniques will include: Jigsaws, Team Based Learning, TED talks with supplemental discussion
groups, content readings paired with lectures, self-directed learning , and application exercise
labs (e.g., self CBT, sleep projects, personal projects) , and integration into clinical care/clinical
decision making while on rotations in order to reinforce real- life Resilience skills. Mentors and
advisors will reinforce Resilience principles and skills in small group and individual sessions with
students.
~Implementation
Addressing Political support & Overcoming Barriers
1. HSP/In-house longitudinal Burnout research : completed
2. Pilot biofeedback curriculum ( meeting September 2013)
3. Developing robust, relevant assessments
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Sharing of information: Use of Wordpress to house all Resilience Literature & Resources
Coordination along teacher-learner continuum: UME , GME, CME
Developing integrated research arm for continuous feedback and publication of results
Map to final competency document.
Faculty development (coordinate with Dr. Leslie Fall; All faculty trained on Self-theory,
Resilience principles; Dr. Ann Davis piloting session in OB-GYN October 2013)
9. Strong focus on the “buy in “ issue :
a. Resilience does NOT mean accepting avoidable stressors or denial of
negative learning environments, both of which strongly correlate with
burnout. Ethics & Humanities in their reflections will reinforce Resilience.
b. Evidence and experience indicate medical students/physicians are more
likely to embrace Resiliency training :
i. If Resilience education is strongly and articulately connected to
Scientific evidence, patient care and productivity (i.e., Focus on
“Wellbeing” is not as appealing and may be off-putting).
ii. Presented in interactive, experiential formats.
iii. Longitudinally and consistently reinforced to encourage “transfer” of
the knowledge and generalizability across settings.
iv. If the curriculum is delivered by practicing physicians.
v. Strong foundation and reinforcement of empirical, neurobiological
foundations.
~ Evaluation Metrics and Feedback
Assessment of Program effectiveness and the impact on individual Learners will be conducted
longitudinally using specific metrics to assess factors of Burnout, changes in Resilience, student
Wellbeing (including measures of anxiety and depression) and learning “style” (fixed/static vs.
incremental/continuous), as well as faculty, mentor and advisor satisfaction with the Practice
Resilience curriculum based on the Geisel competencies. Using Kern’s iterative framework for
curriculum design we will feed back data gleaned from the evaluation process into a continuous
improvement cycle where the curriculum will be further refined. The Resilience Advisory Board
will provide multi-subspecialty oversight for this process and includes practicing clinicians from
a wide variety of specialties . We expect to generate and publish papers in order to share our
project’s methodology and results which will benefit other institutions and will extend the
literature in Resiliency, Burnout and Wellbeing in the context of medical education and medical
practice. Assessment tools under consideration pending final competencies include:
1. Knowledge based assessment of content
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2. Completion and evaluation of laboratories and self-directed learning project including
possible Personal improvement Project ( similar to one currently used in the Leadership
Preventive Medicine Residency)
3. Connor-Davis Resilience Scale
4. Maslach Burnout Inventory
5. PHQ/SCL-90 (measures of anxiety, depression, wellbeing)
6. Dweck Inventory (measures incremental versus fixed views of intelligence)
7. Faculty Satisfaction/Effectiveness Surveys
~Faculty Development
We anticipate needing approximately 5-10 hours of training time with Advisors, Mentors, OnDoctoring Faculty and Select Clinical Faculty (SBM Course Directors, Clinical Rotation Leaders)
to introduce them to the Resilience principles, theory of “incremental” versus “fixed”
intelligence, teaching techniques (jigsaws, personal projects, CBL, CBT, Experiential exercises,
etc.), assessment methodology and the strategic points of learning in the re-designed 4 year
Geisel Curriculum. A pilot faculty development will occur in October 2013
Appendixes
Appendix One
I.
DRAFT EXAMPLES OF POSSIBLE CURRICULUM
( superscripts note the “mapped” Resilience Factor/s from the RAND report; see Appendix I
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Neuro bioscience presentation on stress and biofeedback Lab.i
Stanford anesthesia and surgery residents have a didactic presentation on
neurophysiology that is applicable to them during times of stress ( e.g. : Patient
crashing in operating room ) Integration possible with nuero-anatomy brain
sectioning .
The didactic presentation is followed by a neurophysiology biofeedback lab where
residents learn to control their heart rate and respiration.i
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Engaging in lifelong learning: ii
Curriculum with tenets similar to “Brainology” self-theory curriculum to improve
engagement in lifelong learning ( learning goals) and ability to utilize feedback. For
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medical students this must be based on biomedical evidence of differences in
entity and incremental mindsets , such as fMRIs and ERPs. The instruction would
include strategies to move learners to incremental mindsets.ii,iii( Dweck et al and The
Power of Belief - Mindset and Success: http://youtu.be/pN34FNbOKXc)
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Self Care: iii
Example 1.Medical schools and CME have often addressed the issue of sleep hygiene
in “wellbeing education” in didactic/grand round or eLearning formats. There is a
dearth of material that this type of didactics actually changes behavior.
From an educational vantage a more ideal longitudinal approach might be :
Student is given presentation on sleep hygiene in pulmonary pathophysiology.
Project/Laboratory experience. Students may engage in a Personal Improvement
Project ( similar to PIPs in the LPMR) and chart their own sleep behaviors with
specific goals to practice sleep hygiene. This could involve sleep monitoring devises.
A similar project has been done with/by Geisel students. Dr. Sorscher will assist in
developing this curriculum ..
(In addition this a similar PIP could utilize the curriculum to understanding the use
of CBT (cognitive behavioral therapy).ii CBT is presented as a useful tool to use in
patient care. Similar CBT “PIPs” in medical students have been published in
Academic Medicine.)
Later in the curriculum a case is imbedded (“hidden”) with a medical error in
obstetrics when a sleep deprived obstetrician misreads a NST.1iii This allows
reinforcement and transfer of the curriculum on sleep hygiene, discussion of ethics,
and control of the working environment: why did this physician not apply what they
knew about sleep hygiene? Is this ethical? How can they control their work
environment (an avoidable stressor?).
Example 2. Self-directed learning using a Personal improvement Project directed as
an evidenced based resilience factor. This currently is included in the Leadership
Preventive Medicine Residency and has also been utilized in the Ob-Gyn interns.
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Mindfulness: The literature is filled with evidenced based medicine documenting
mindfulness improves/facilitates many resilience factors including behavioral control,
positive coping, realism and self-efficacy ( all evidenced based/informed resilience factors
from the Rand Report. Mindfulness is also a skill that can be taught to empower patients to
address some of their most vexing medical challenges (e.g. weight loss, tobacco, anger
control).
Based on the experience of other schools and a focus group of Geisel Health Society and
Physician students it appears that a significant portion of medical students will be “leery”
of mindfulness as it may sound too unscientific ( the so called “woo-woo” factor) . The
nuero -science of mindfulness must be included in this part of the curriculum. It may be
referred to as an “awareness “curriculum in course schedules. Besides a neuroscience
underpinning various videos/clips/exposures to respected physicians who use mindfulness
may be helpful to normalize this approach.
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Applicability to medicine
This curriculum also meets the goal of increasing “buy in”. Students read 4
articles specific to 4 different medical specialties on “unavoidable stressors of
medicine” guided by objectives or would be asked to make their own objectives.
They then do a jig saw initially with a specialist in each specialty followed by cross
pollination to the class. ( Examples: Surgery: Annals of Surgery 2009: Burnout and
Medical errors among American Surgeons; Psychiatry : Academic Psychiatry 35:6 ,
2011: Burden and Stress among Psychiatry Residents and Psychiatric Health Care
Providers; Pediatrics: Critical Care Med 28:9, 2000 Experience and endocrine stress
responses in neonatal and pediatric critical care nurses and physicians ) iv
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Productivity/time management: Use the Harvard business review article to educate
students on strategies that are evidenced based to increase productivity and
wellbeing. *( HBR, Swartz T: Mange your energy , Not your Time, 2007)v Students
also exposed to evidenced based learning strategies . Another example is teaching
the Coveys 4-Quadrant approach showing inattention to quadrant 2 is associated
with burnout ; an antonym of resilience. Iii
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Appendix II.
Evidence based/ informed resilience factors addressed by the curricular examples in
Appendix 1 and excerpts from RAND
Bolded indicates strong evidence
Behavioral control: process of monitoring, evaluating, and modifying emotional reactions
Positive thinking:
informational processing, applying knowledge, flexibility, reappraisal flexibility, having
positive outcome expectations, psychological preparation.
Realism: mastery of possible, having realistic outcome expectations, self-efficacy, perceived control
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Positive affect: feeling enthusiastic, active, and alert
Positive coping: managing taxing circumstances
Realism: mastery of possible, having realistic outcome expectations, self-efficacy, perceived control
Physical fitness: bodily ability to function efficiently and effectively
iv Realism: positive coping, teamwork, positive team climate,
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Positive affect
Realism
Positive thinking
Physical fitness
Appendix III
List of evidence based/informed resilience factors from US Army: RAND report
Promoting psychological resilience in the US military
not to be disseminated for commercial purpose
Attribution: Direct excerpts
Which resilience factors had the strongest evidence in the RAND literature review?
“The individual-level factors with the strongest evidence in the literature were positive thinking,
positive affect, positive coping, realism, and behavioral control. These factors were rated as
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having either moderate evidence (based on cross-sectional correlational or observational design) or
strong evidence (based on a randomized design or other longitudinal design).
Among the family-level factors, family support had the most evidence.
For unit-level factors, positive command climate had the most evidence.
For community-level resilience factors, belongingness had the most evidence”
List of all evidenced based/informed resilience factors from their literature search:
Factors That Promote Resilience: Findings from the RAND Literature Review
Using the working definition of psychological resilience specified (Psychological resilience refers to
the process of coping with or overcoming exposure to adversity or stress. With regard to mental
health interventions, psychological resilience is more than an individual personality trait—it is a
process involving interaction among an individual, that individual’s life experiences, and current
life context) we conducted a systematic review of the scientific literature on psychological
resilience. The review had a twofold purpose:
• to identify evidence-informed factors that promote psychological resilience (i.e., resilience
factors)
• To assess the strength of the evidence base associated with each factor.
We identified 270 relevant publications. The initial set of evidence-informed factors for
promoting psychological resilience, based on these publications, was identified by the research
team. These evidence-informed factors were confirmed by an expert review process, yielding 20
evidence-informed factors associated with resilience. We categorized these resilience factors
according to whether they operated at the individual, family, organization (or unit), and
community levels. We used such an organizing framework to distinguish intrinsic factors that
promote resilience within an individual from resilience factors that involve other individuals who
are part of a group (e.g., family, organization, community). Each factor is listed and defined
below.
Individual-Level Factors
• Positive coping. The process of managing taxing circumstances, expending effort to
solve personal and interpersonal problems, and seeking to reduce or tolerate stress or conflict,
including active/pragmatic, problem-focused, and spiritual approaches to coping
• Positive affect. Feeling enthusiastic, active, and alert, including having positive emotions,
optimism, a sense of humor (ability to have humor under stress or when challenged), hope, and
flexibility about change
• Positive thinking. Information processing, applying knowledge, and changing preferences
through restructuring, positive reframing, making sense out of a situation, flexibility,
reappraisal, refocusing, having positive outcome expectations, a positive outlook, and
psychological preparation
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• Realism. Realistic mastery of the possible, having realistic outcome expectations, selfesteem and self-worth, confidence, self-efficacy, perceived control, and acceptance of what is
beyond control or cannot be changed
• Behavioral control. The process of monitoring, evaluating, and modifying emotional
reactions to accomplish a goal (i.e., self-regulation, self-management, self-enhancement) •
Physical fitness. Bodily ability to function efficiently and effectively in life domains
• Altruism. Selfless concern for the welfare of others, motivation to help without reward
Family-Level Factors
• Emotional ties. Emotional bonding among family members, including shared recreation
and leisure time
• Communication. The exchange of thoughts, opinions, or information, including problemsolving and relationship management
• Support. Perceiving that comfort is available from (and can be provided to) others,
including emotional, tangible, instrumental, informational, and spiritual support
• Closeness. Love, intimacy, attachment
• nurturing. Parenting skills
• Adaptability. Ease of adapting to changes associated with military life, including flexible roles
within the family
Unit-Level Factors
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Positive command climate. Facilitating and fostering intra-unit interaction, building
pride/support for the mission, leadership, positive role modeling, implementing institutional
policies
• Teamwork. Work coordination among team members, including flexibility
• Cohesion. Unit ability to perform combined actions; bonding together of members to sustain
commitment to each other and the mission
Community-Level Factors
• Belongingness. Integration, friendships, including participation in spiritual/ faith-based
organizations, protocols, ceremonies, social services, schools, and so on, and implementing
institutional policies
• Cohesion. The bonds that bring people together in the community, including shared values
and interpersonal belonging
• Connectedness. The quality and number of connections with other people in the
community; includes connections with a place or people of that place; aspects include
commitment, structure, roles, responsibility, and communication
• Collective efficacy. Group members’ perceptions of the ability of the group to work
together
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