"That which does not kill us, makes us stronger!"

It's a popular misconception that the singer/songwriter and former American Idol, Kelly Clarkson, came up with the saying "What doesn't kill you makes you stronger".  Surprise!  It was actually the German philosopher, Friedrich Nietzsche, whose original line (in German, of course) was "Was mich nicht umbringt macht mich starker."  The line translates to "What does not kill me makes me stronger" and comes from the "Maxims and Arrows" section of Nietzsche's book, Twilight of the Idols, or, How to Philosophize with a Hammer, written in 1888.  Clarkson or Nietzsche - they are both basically saying the same thing.  We grow through adversity.  We learn and improve from our mistakes. 

For the first 10 years of my professional career, I researched something that is commonly called the heat shock response.  Basically, the heat shock response is a form of stress adaptation or tolerance that has been described in almost every organism examined to date, including humans.  In essence, expose something living to a little bit of stress and that same living thing develops a resistance to an even greater level of stress with the next exposure.  The heat shock response was originally described with heat stress - expose a cell or organism to higher than normal temperatures for a brief time and the cell or organism develops a resistance to an even higher, and often lethal, temperature exposure the next time.  These cells or organisms increase production of a specific family of proteins, known as heat shock proteins, that appear to be critical to the subsequent resistance to a lethal heat stress.  What is really cool is that these heat shock proteins protect the cell or organism from a variety of stressors, not just heat stress.  In other words, whatever doesn't kill the cell or organism makes them stronger the next time.

I received a comment on one of my previous posts a few weeks ago ("Dad is hangry again!") that I believe is relevant to the present discussion.  Basically, the individual asked a really good question to my comment that one should "Never make an important decision when you are tired or mentally drained."  I will fully admit, during my career working in the Pediatric Intensive Care Unit, I have made important decisions while dealing with lack of sleep, hunger, and stress.  But here is my point.  I didn't start out that way.  During my training over the course of my medical school education and subsequent residency and fellowship training, I learned to work for long hours, often without getting enough sleep or taking time to eat.  There was always a safety net of supervising physicians and nurses who made sure that I made the right decisions.  I learned to deal with the kind of stress that goes with working in a busy intensive care unit.  I was gradually given more and more responsibility, until I eventually found that I was the one supervising the younger physicians.

Please don't misunderstand me.  I do not have a hero complex.  I am sure that I have made some mistakes at the end of a long shift overnight in the Pediatric Intensive Care Unit.  I am not perfect.  I am not superhuman.  What I am saying is that I learned to work within the system.  I learned to work with the other members of the team.  I learned to trust and rely upon these same individuals.  I learned how to make decisions, some times under less than ideal conditions.  I don't think I could have made these decisions or done the job as well when I first came out of medical school.  Lack of sleep, hunger, and stress had a much greater impact on my ability to make decisions early on in my career.  In other words, I, like all of my colleagues who work in the hospital, developed a kind of heat shock response or stress tolerance over time.

I know what you are thinking.  But here's the thing.  The military has figured this out too.  If you look closely at the kind of training that special forces in the military go through, there's a lot that you will find in common.  The Army, Air Force, Marines, and Navy each have their special forces units.  All of the soldiers and sailors go through a period of training before they become part of these same units, and the training is remarkably similar.  Soldiers and sailors are exposed to incredibly difficult and stressful work conditions.  For example, the U.S. Navy SEALs go through something called "Hell Week" during BUD/S training during which time they may have a total of four hours of sleep the entire week!  Part of this is a test - if you want to become a Navy SEAL, you have to last through "Hell Week."  But it's more than just a test, it's also training.  Navy SEALs begin to learn how to handle the tough conditions that they are likely to encounter (lack of sleep, lack of food, incredible stress) on the combat missions they will go on during their careers.  Sound familiar?  The Navy SEALs first develop stress tolerance during "Hell Week."

The military has developed specific training programs that focus on making decisions under stressful conditions.  For example, there is an entire program called TADMUS ("Tactical Decisionmaking Under Stress") with an accompanying textbook that is really quite interesting that was co-edited by the cognitive psychologists, Janis Cannon-Bowers and Eduardo Salas.  I read the book several years ago and was left to ponder whether there was something here that we could apply in health care.  If we can train soldiers and sailors to make critical, high impact decisions under the stressful conditions of combat, then surely we can train clinicians to make those same kind decisions under the stressful conditions that occur on any given day in the hospital.  What exactly did the TADMUS program involve?  Repetitive training under incrementally increasing stressful conditions.  In other words, stress tolerance, or the heat shock response.

I would be interested in hearing from others here.  I could be wrong, but I do believe that we can train clinicians to work effectively and make important decisions under stressful conditions.  We can't expect individuals who have never been exposed to these situations to make important decisions.  But with training and progressive exposure, perhaps we can.  The current approach, which has emphasized restricting the length of shifts in the hospital or the number of hours worked (so-called "duty hour restrictions") hasn't necessarily resulted in the expected improvements in patient safety and quality of care (there are many studies that show this, see one study here).  We clearly need a different approach.  Perhaps stress tolerance is that approach.

Maybe Kelly Clarkson was right.  Or was it Nietzsche?