- Maria Margaritis
The 3 Best Resilience Strategies for IMGs in Canada
Try the 3 best resilience strategies for IMGs in Canada to perform at your best during the match and residency training.
What do cookies have to do with resilience? Aside from being delicious, thinking about cookies can actually change your point of view AND energy levels during times of stress! As a newcomer to Canada and IMG (international medical graduate) you are going to be confronted with obstacles that will seem never-ending and impossible to overcome. DON’T GIVE UP! Remember, it’s a marathon not a sprint. If you are already in Canada, then you ARE resilient! These particular cookies are going to help you remember your strengths at times when you feel fragile. Discover which of the three best resilience strategies for IMGs in Canada will work for you!
What is resilience and why should you care?
Resilience is described as having the ability to ‘bounce back’ after difficult life experiences or challenges. Specifically, being resilient means having the ability to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost. As a newcomer to Canada, you are likely to experience high levels of stress due to relocating, adapting to a new culture or climate, the physical distance from your friends and family, not to mention navigating the complicated, expensive and competitive journey as a medical trainee (i.e. IMG) in Canada.
On top of personal stress, Canadian doctors are especially vulnerable to anxiety, depression and suicide. It’s not just because doctors are responsible for patient health, but because of systemic issues that require more attention to policies, procedures and administrative duties. The complexity of personal, interpersonal, and systemic issues are not always in your control, so it is important to begin your life in Canada by consciously developing strategies that will help you cope with stress throughout the course of your journey.
The Grim Facts: Doctor wellness in Canada
The Canadian Medical Association recently published a survey highlighting that doctors in practice for five years or less were more likely to experience burnout and have low resilience compared to all other physicians. The same survey also revealed that medical residents had higher rates of burnout, depression and lifetime suicidal ideation than practicing physicians, and this was higher for women than men.
Along with the system-level recommendations made in the survey, the onus was also placed on individuals to be proactive by maintaining their own self-care and well-being. This may be easier said than done, considering the top barriers to seeking help mentioned in the survey included:
- Believing the situation is not severe enough
- Ashamed to seek help
- Not aware of the range of services available
All three of the top barriers involve HOW YOU THINK about the situation. The way you think can influence which action you will take when deciding about getting help. Let’s be clear–IF YOU NEED HELP, GET IT! The sooner you get support the easier it will be to keep your level of stress manageable. (Disclaimer: I am not a medical professional and do not provide medical advice. Some helpful resources to find support are listed at the bottom of this page. Learn about me here.)
In addition to seeking help from others, there are things you can do to build resilience and stay healthy. Developing skills that help you understand your mind and body during stressful times can help you overcome challenges by expanding your self-awareness and helping you stay present when stress starts to escalate.
The Good Facts: You have superpowers!
Our thoughts have the power to supercharge our mind and body beyond normal limits. Practicing resilience strategies now can reduce the effects of stress later. The following three strategies are science based and simple to do anywhere, anytime. This is an important factor to consider, since you will need to draw from them while you are experiencing high levels of stress and weakness.
The catch is, they need to be included in your regular routine so that they become habits. Try pairing each of the strategies with a habit you already practice, such as (but not limited to):
- brushing your teeth
- washing your hands
- taking a shower
It’s good to pair these strategies with personal hygiene habits because the likelihood of becoming part of your daily routine is higher. You are also less likely to be distracted, as personal hygiene habits are done at times when you are alone.
Strategy #1: The Cookie Jar Method
The Cookie Jar Method is credited to David Goggins, a former U.S. Navy SEAL, accomplished endurance athlete, motivational speaker, and author of Can’t Hurt Me: Master Your Mind and Defy the Odds. This method is a creative visualization technique to help you identify events in your life when you overcame hardships and achieved your goal. The cookies in the jar provide specific reminders of who you are and how far you have come on your life’s journey. The purpose of this strategy is to build motivation and perseverance at times of adversity or weakness. The Cookie Jar Method helps keep personal memories of specific accomplishments (i.e. evidence of your capabilities) in the present so you don’t forget how resilient you are.
Your task: Get a few small pieces of paper and a pen. On one side write about a failure or weakness you experienced. On the other side write how you overcame that challenge and what you achieved despite the obstacles you faced. Put all the papers in a jar. These papers represent “cookies”. Consider each statement you read a “bite” of that cookie. Now put your hand in the jar, grab “a cookie” and “take a bite”. Pay attention to any sensations in your body or emotions you experience. Do you feel more energized or confident? Try to do this activity once a day. Add to the jar each time you overcome a new challenge.
Suggested practice time: in the morning when you brush your teeth, so you start the day confident
Use it: at times when you feel overwhelmed by challenges that seem impossible to overcome, you are afraid to confront something, or you feel like giving up
The Science
If you believe it you can achieve it. Researchers claim that people have the psychological resources to improve their well-being and performance, but most people are not aware of those resources (Weger & Laughnan, 2013). In other words, your performance can be influenced by your expectations. The researchers suggest that negative self-perceptions are debilitating and may be responsible for triggering psycho-physiological reactions such as anxiety or fear, that limit our ability to perform at our full potential. Performance is enhanced when these negative thoughts are eliminated. This decreases stress and allows us to tap into those unknown resources so we can execute our personal best. The Cookie Jar Method helps you to believe in yourself and your capabilities.
Remembering the “good times” can also reduce the negative effects of stress on the body and mind. A recent study demonstrated that reminiscing about happy times results in positive feelings and enhances well-being (Speer & Delgado, 2017). Thinking about happy memories dampens cortisol rise and reduces negative emotions. The participants in this study who reported higher levels of resilience showed enhanced mood, despite exposure to stress. The researchers concluded that personal happy memories (positive autobiographical memories) can restore and protect individuals during stressful times. So, bite into that cookie and remember the sweet taste of victory to get you through the hard times!
Strategy #2: Positive Reframing
The best approach to building physician resilience is by developing strategies and attitudes that cultivate effective decision making for personal and patient care. Are you the type of person to see the glass half full or half empty? Are you an optimist or pessimist? The way you think can affect your health and well-being and that of your patients.
Positive reframing is a psychological term used to describe thinking optimistically. Self-talk is the inner dialogue of automatic thoughts that run through your mind and can be positive or negative. Positive reframing helps reconstruct negative self-talk so you can see things from a positive perspective. This strategy helps to reduce stress, while improving health and well-being. The hard part is that it takes more effort for humans to change negative thinking to positive thinking. If you tend to be pessimistic, don’t worry. You can learn this skill with practice and a healthy dose of persistence.
A note about attitude…
Your attitude can influence your interpretation of events and impact the decisions you make. Individuals who choose to become doctors tend to have certain personality traits and habits that, if left unbalanced, can lead to physician distress. Perfectionism is a trait that many doctors have, and in extreme cases can result in feelings of frustration, leading to relentless criticism of oneself or others (Wong, 2020).
Under the CanMEDS role of Professional, the College of Physicians and Surgeons of Canada expects Canadian physicians to demonstrate their commitment to personal health and well-being as part of the physician key competencies. You can be proactive by expanding your self-awareness and managing things that influence your personal well-being and professional performance. How? Positive reframing. Below is an activity you can do to monitor your attitude. All you have to do is pay attention to your self-talk and classify it as positive or negative.
Your task: Pay attention to your automatic thoughts throughout the day. Write them on paper, in a text or as a voice recording on your cell phone. Reflect on those thoughts (e.g. while washing your hands). Ask yourself if this thought is constructive or helpful in any way. Can you see the situation from different perspectives? Reconstruct any negative thoughts using positive reframing. Record those reframed statements in writing, text, or voice recording. Here are some examples of negative thoughts modified using positive reframing:
Negative Thoughts
- I’m not good at this.
- I made a mistake. I’m such an idiot!
- I don’t know what services are available.
- I don’t have time to access resources.
- I’ll never be like them.
- Seeking wellness support means I can’t handle my responsibilities.
- I don’t make enough money to socialize.
Positive Reframing
- I’m going to figure out a way to do this better.
- Now I’ll know what to do next time.
- I will ask a trusted colleague for suggestions.
- Today, I will schedule 10 minutes to access resources.
- My differences help me understand and solve problems others cannot.
- The Wellness Support Line exists because other doctors need support, too.
- I can check my local city’s parks and recreation to see what free social activities are available in my community.
Suggested practice time: when you wash your hands. Do the task before (remember), during (reflect) and after (reframe) handwashing. Doctors do this a lot! It’s a convenient and repetitive opportunity to practice positive reframing so it becomes a habit!
Use it: when your self-talk is negative. Examples include (but are not limited to) times when you are:
- being critical of yourself or others
- ruminating about negative feedback
- seeing your situation in extremes of only good or bad (polarizing)
- spiralling into negative thought patterns of worst case scenarios (catastrophizing)
- believing all negative events are your fault (personalizing)
- focusing on the negative things said about you and losing sight of the compliments (filtering)
- magnifying what you did wrong and minimizing what you did well (filtering)
The Science
If every fifth physician is affected by burnout, what about the other four? This research question was posed by German scientists Zwack and Schweitzer (2013) to identify which health-promoting strategies experienced physicians used to build resilience. They found that doctors with positive attitudes and good self-awareness were better at coping with stress and were able to maintain resilience-promoting strategies throughout the duration of their medical careers. Cognitive interventions that help physicians develop positive attitudes and perspectives (e.g. positive reframing) are one of the approaches recommended for building physician resilience.
A team of scientists analyzed previously published studies on optimism, pessimism, and health to evaluate whether the presence of optimism or the absence of pessimism predicted positive physical health more strongly (Scheier et al., 2020). The team found that the presence of optimism combined with the absence of pessimism was a reliable predictor of physical health. However, the absence of pessimism was more strongly related to positive health outcomes than the presence of optimism. Cognitive interventions that focus on restructuring of negative thoughts may be more successful at promoting better health than interventions that merely focus on optimism.
According to research, the Mayo Clinic Staff list the following as some of the known health benefits of positive thinking:
- Increased life span
- Lower rates of depression
- Lower levels of distress
- Greater resistance to the common cold
- Better psychological and physical well-being
- Better cardiovascular health and reduced risk of death from cardiovascular disease
- Better coping skills during hardships and times of stress
Looking at the positive side of things takes effort. Bad habits are hard to break, whereas good habits need consistent practice to stick. It is important to be patient with your own personal process and accept that change takes time. Alison Ledgerwood, a UC Davis professor of psychology, studies how we tend to get stuck in particular ways of thinking and what we can do to get unstuck. In this video she discusses her research and how to get out of the negative frame of thinking.
Strategy #3: The S.T.O.P. Technique
The degree of resilience you have is reflected in your ability to control yourself when exposed to stress. The term self-regulation refers to your ability to control your own emotions, thoughts, and behaviours. Self-regulation involves the way you react to your environment, as well as the quality of recovery and restoration you experience after a stressful event. But, what if you aren’t aware of your behaviour, thoughts and emotions?
Canadian physician Stephen Liben MD writes about the informal mindfulness practice S.T.O.P. in the teaching guide MD Aware. Informal mindfulness is when you incorporate mindfulness practices into your daily routine by intentionally creating moments to process your actions (i.e. What am I doing now?) and your present state of being (i.e. How am I doing now?). Basically, you are taking a minute to check-in with yourself to assess your level of stress, manage it, then work calmly and effectively with clarity.
Together with Dr. Tom Hutchinson, Liben created the Mindful Medical Practice Course (MMP) for medical students at McGill University and co-authored the MD Aware guidebook on how to teach MMP core clinical skills. So what is the S.T.O.P. technique? S.T.O.P. is an mnemonic for the following self-regulation skills:
- Stop
- Take a breath
- Observe
- Proceed
The “S” stands for stop as in pause for a moment. This is an intentional break you take from the thoughts running through your mind. You can do this while standing still or even walking from one room to another. Specifically, in your mind’s eye disconnect from autopilot and reconnect with yourself, the human. Taking a breath causes you to physiologically slow down and take note of your breathing. Observing directs your attention to your inner thoughts, emotions and sensations that might be out of balance. Once you’ve done a brief scan of your current state you can center and ground yourself before proceeding with your routine.
The skills you develop using S.T.O.P. help you manage stress by requiring you to deliberately pay attention to the current state of your body and mind. Practicing the S.T.O.P. technique can help you expand awareness of the sensations in your physical body (somatic attunement), as well as emotions and thoughts that may be running through your mind. With practice, you can gain control over the way you react to things happening around you. Over time, you can become less reactive and more responsive, building personal resilience as well as providing better patient care. The better you are at responding to stress, the more effective you will be at protecting your health from the negative effects stress can have on your body and mind.
Your task: The S.T.O.P. exercise is an “invisible” process. Other than you, no one else can see or understand what is happening because it is taking place in your mind. The steps you practice in this task can be transferred into the workplace or any other environment. You are practicing non-judgemental self-awareness and self-monitoring in the present moment.
Before stepping into the shower as you normally do, STOP your mind chatter (self-talk). TAKE A BREATH by inhaling for 2 seconds, holding for 1 second, and slowly exhale for about 3 seconds until you are at a resting state. Step into the shower and get under the water. Bring your attention to the sensation of water as it sprays onto your head. Hold your focus there as all of your head gets wet. OBSERVE. Identify and name the temperature of the water (e.g. warm, tepid, cold) and the sensation the spray of water makes as it hits your skin (e.g. tickle, warmth, invigorating, harsh, relaxing, painful). Do you need to adjust the temperature or pressure? Do you need to adjust your physical position in the shower? Make any necessary adjustments and PROCEED with your shower routine.
Suggested practice time: in the shower. Whether this occurs at the end of your shift, before you go to bed, or when you start your day, it’s an effective time and place to clear your mind and practice how to connect with yourself in the here and now.
Use it: when you are overly stressed or are multitasking during a busy day. If it seems like your day is all a blur and everything starts to blend together, take a break. Or, you feel irritated, tired, anxious and just not your typical self, it’s the perfect time to reconnect with yourself by doing a quick scan using the S.T.O.P. technique.
The Science
Mindfulness practice has been identified as an effective strategy to enhance physician resilience and may reduce physician stress, burnout, anxiety and depression. Specifically, self-awareness, self-monitoring, and mindfulness-based stress reduction techniques (e.g. self-regulation) were found to be as effective as techniques to reduce the negative feelings of emotional distress and rumination while enhancing a physician’s capacity for empathy. Both self-awareness and self-care are viewed as teachable skills and can be enhanced. It is called mindfulness “practice” for a reason. If you want it to feel natural, you need to PRACTICE! Superheroes/heroines aren’t born, they’re made!
Birtwell and her colleagues (2019) were curious about formal and informal mindfulness practices and the relationship they had with well-being and psychological flexibility. The team explored the experiences of people already practicing mindfulness and found that more of the participants practiced informal mindfulness on a daily basis than formal mindfulness. Moreover, the results of their study suggest that the frequency of informal practice was more important to positive well-being and psychological flexibility than the duration or frequency of formal mindfulness.
Birtwell et al. also highlighted the importance of recognizing that mindfulness practices have no ultimate goal or state that needs to be achieved other than becoming aware of things as they are and that the experience of mindfulness practice is ever changing. The important thing to highlight here is that you don’t need a fancy club or expensive yoga gear to benefit from mindfulness practice. The capacity to be mindful is within you, in your control, and is just as clinically important a tool as your stethoscope!
In Epstein and Krasner’s (2013) commentary about physician resilience, they emphasize the importance of self-awareness and self-monitoring as skills that are essential to help you recognize first, if stress is affecting you and second, if the way you cope with stress is adaptive or maladaptive. The ability to identify early warning signs of maladaptive behaviours, sensations, or emotions (e.g. irritability, anxiety, fatigue, skipped meals, insomnia) is necessary because that is when you know it’s time to draw from your repertoire of self-regulation strategies. The S.T.O.P. technique is one way you can build the skills of non-judgemental awareness and self-monitoring. After you’ve stopped to observe yourself, you can decide which of the self-regulating strategies you’ve practiced will help you become centered and grounded before proceeding with your routine.
Building these skills will not only help sustain your professional competence, but also nourish and protect your own sense of well-being for long term resilience (Zwack & Schweitzer, 2013).
Which of the 3 Best Resilience Strategies for IMGs in Canada will you use today? Let me know in the comments below!
Resources for help in Canada
If you or someone you know is in immediate danger, please call 9-1-1 or go to your nearest hospital.
To find crisis services nearest to your location in Canada go to Crisis Services Canada.
- If you are a medical trainee, doctor or family member of a doctor/trainee and need emotional support, help is available through the Canadian Medical Association Wellness Support Line.
- If you live in Canada you can find Mental Health Support through the Government of Canada.
- If you are a Canadian Newcomer seeking multilingual mental health services check the Canadian Mental Health Association Help for Newcomers.
- If you are alone in Canada check out Settlement.org’s self-help guide.
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