Resigned Compliance

In The Body Keeps the Score, Psychiatrist and Trauma Expert, Bessel Van Der Kolk, MD, writes about the effects of trauma on the body and mind. Most Physicians would not self-identify as experiencing PTSD, but my guess is that if we could measure the degree to which we experience lasting somatic and psychological consequences of experiencing both primary and secondary trauma, we would find that its effects are far more prevalent than we recognize.

One place where I frequently encounter this with Physicians is how many of us will persist in resigned compliance. Dr Van Der Kolk writes “When people are forced to submit to overwhelming power, as is true for most abused children, women trapped in domestic violence, and incarcerated men and women, they often survive in resigned compliance.” Many Physicians have described frankly abusive situations during their training, where the goal of the leaders seemed to be to create the same resigned compliance that a rape perpetrator might want from someone they attack. I personally would not equate any parts of my medical training with the experience of these macro-traumas, but I have seen in myself and others that the cumulative effects of micro-traumas and/or episodes of recurrent moral injury (not necessarily the same thing) leads to this phenomenon of passivity and futility. 

What does this look like?

It looks like giving up on trying to improve effectiveness in their days, expecting suffering, and extreme passivity.

Many of the Physicians I talk to feel that advocating for themselves just isn’t worth it. This could be related to a change in FTE or compensation, particularly for those paid by productivity models where pay could be owed back retroactively, even during a pandemic. It can mean not agenda-setting with patients, and tackling all of the issues and questions they have, despite 4 more patients waiting, and an angry MA knocking on the door. It can mean hours and hours of pajama-time and weekend work, or vacations spent closing 70+ open charts, and accepting that this is par for the course. 

It isn’t that they have a desire to be this way, or that they don’t want things to be different. But of course overwhelmed Physicians are often sleep-deprived, paying off school debts as well as other financial contracts, such as mortgages, and aren’t used to thinking of themselves as having agency and choice in their own lives, especially as young Attendings. Because for years during training, they had very little agency or control. And for those of us with people-pleasing or perfectionist tendencies, who got a dopamine hit from pleasing others, or scoring high marks, we may feel that there is no other choice but to continue to subsist in this way for many years after training.

There are a number of different avenues forward to combat this mindset, but for now I will draw from this trauma-work, one of the more effective tools for helping people experiencing PTSD. Dr Van Der Kolk describes a model-mugging program, that teaches self-defense to people who have already experienced a traumatic experience, such as rape or mugging. In building these attack skills and practicing using them over and over again, the individual can then rewire their fight/flight response towards action, which may have been impaired during the trauma. Their brain is no longer stuck; it has a new neural pathway wired that is responsive in an empowered way should it encounter the trauma again.

How might this look for us in medicine?

Imagine scenarios that come up in your life, where you feel a loss of power, or autonomy. This could be negotiating a job or a job change, it could be your experience with difficult patients in the exam room. What if you started to do the work to build skills around boundary-setting, being willing to disappoint others, and the like, and then play through those same scenarios. We don’t undo the past by doing this, but we do give our brain a different idea, a new lens of possibility in which to see this and similar experiences, which goes into our bank of tools. The goal here is also not to bring blame or shame to what has happened in the past, but to look at the situation with self-compassion and turn our attention to how it might look different when we are empowered and skilled in countering “the attack.”

Doing the work to build skills to unlearn people-pleasing, perfectionism and human giver syndrome is necessary for many of us who struggle with burnout. Yes, THE MEDICAL SYSTEM needs to change, and could do a lot to address the experience of burnout. However, because burnout includes patterns of cynical thinking, of feeling that our work is futile (but also essential), and being depleted, external fixes will not be sufficient to address our individual need to restore wholeness, agency, and joy. That, my friends, is an inside job.