Metaphorically, flourishing connects us with images of trees, flowers, gardens Click To Tweet

Introduction

In parallel with increasing burnout, depression, anxiety and suicide, there has been growing interest in physician resilience’ and how to promote it (Teodorczuk et al, 2017). The concept of resilience, however, and the way it is being used in medical education and healthcare is not always welcomed by our students and healthcare professionals, where it can become another competence to strive for in the midst of struggles or a tool to silence beleaguered people working or learning in difficult contexts. Flourishing is a concept that offers a different way of thinking about and engaging with this ‘burnout epidemic’ among clinicians and students, particularly as we face up to our Covid-19 pandemic. In this paper I propose that flourishing has metaphorical depth, it has increasingly been the subject of psychology research and also has philosophical roots. It rarely appears in medical education literature or parlance.

Resilience

Resilience has been held up as the new panacea to address our ‘wellness crisis’ in the field of medicine (Teodorczuk et al, 2017). Typically, resilience is framed as
an individual capacity to remain positive and ‘bounce back’ in the face of adversity drawing on the Latin root ‘resilire’ to ‘spring back’ or ‘rebound’. In the field of the physical sciences resilience is described as the ability of materials to resume their original shape after being bent or stretched, which translated to humans suggests the ability to withstand challenges and remain intact. Resilience thus described might give us the impression it is about the individual capacity to be tough and to return unchanged from our difficulties and traumas, a kind of militarism which lays burnout at the door of the ‘weak’ individual (Van der Kolk, 2014). The temptation is to address complex and multilayered problems with simplistic measures that focus on individuals rather than the contexts they find themselves in it (Teodorczuk et al, 2017) or the histories, challenges and (thinking for example of Black Lives Matter) the inequalities they may have lived through.

What is flourishing?

Flourishing might be thought of metaphorically, philosophically or psychologically. Metaphorically, flourishing connects us with images of trees, flowers, gardens and with these the space to explore loss, growth, interconnectedness and context, mirroring somewhat the complexity of lived experience. A tree loses its leaves in the winter time reminding us of the inevitability of seasons of loss and difficulty, as well as hope and new life. A tree needs space to stretch out their branches and capture sunlight and students need space for meaningmaking and dialogue in a way that supports the finding of their own voices and personal
growth. Caring for our students requires us to listen to them as the experts of their lived experiences, co-creating ways to flourish (Ayala et al, 2017). The hidden roots of a tree help us to remember that students have been nurtured on different soils and will vary on how they weather the medical education storms.

Philosophically, flourishing approximates Aristotle’s concept of Eudaimonia, which has been described as authentic connection with our values, meaningful engagement in the world, the pursuit of excellence and personal growth through challenges (Huta, 2015). A definition (popularised through a speech by John F
Kennedy) describes flourishing as ‘the exercise of vital powers along lines of excellence in a life affording them scope’ (Hamilton, 1993). These philosophical definitions highlight the human importance of purpose, meaning and growth, but in medical education the concept of striving for excellence may be less helpful in a culture already suffering from perfectionism. Further, the impossibility to flourish without the right context denies the potential to flourish in and through difficult times. Research into the field of trauma has on the contrary found not just negative consequences but also the potential for post-traumatic growth. This is where people who have faced huge challenges come out the other side, for example, reappraising priorities and life goals, with greater thankfulness, as well as finding new meaning and purpose in life etc (Hefferon et al, 2009).

There are real benefits in moving beyond the concept of teaching our students to be resilient towards supporting students in their own journey of flourishing

Psychologically flourishing has been researched and measured in work by Keyes (2002), Seligman (2011) and VanderWeele (2017). Keyes created a measurable scale from flourishing to languishing. This considers three dimensions of wellbeing: emotional (feeling happy), psychological (self-acceptance, personal growth, purpose) and social (social integration and contribution). Flourishing has also been promoted from within positive psychology and the work of Martin Seligman with his PERMA model: positive emotion, engagement, relationship, meaning and achievement. The criteria for each of these domains are that they contribute to wellbeing and can be defined and measured independently of the other elements. This PERMA model is the basis of one of the few papers in medical education considering flourishing, where drawing on the different parts of the pneumonic, the authors suggest enhancing meaning through medical humanities programmes or celebrating achievement beyond exams, instead rewarding community service or research etc (Slavin et al, 2011). Another approach to flourishing has been developed by VanderWeele (2017) who makes the case for a six-domain questionnaire that similarly measures happiness, relationship, and meaning. He also proposes mental and physical health, character and virtue (ie someone who promotes good in all circumstances) and financial and material stability. These measurable scales are interesting, though bringing flourishing to medical education may require greater qualitative understanding of what flourishing means to the students of today and collective work on how to promote this (Bynum et al, 2020). Creative enquiry involves student engagement with their lived experience through the arts. This is one approach that has been found to invite flourishing, where expression, sharing and collaborative meaning making lead to growth in understanding of self and other thus building the human connection (Younie, 2019).

In summary, there are real benefits in moving beyond the concept of teaching our students to be resilient towards supporting students in their own journey of flourishing. Although there is work to be done to establish a shared meaning of flourishing in medical education; the responses from students to the following
questions: ‘are you resilient?’ or ‘are you flourishing?’ may be qualitatively very different. The risk is that the former may induce pride or shame on an individual level, whereas the latter may invite exploration of context, culture, learning, meaning and purpose, potentially leading to reflection on self and perhaps a call to
challenge the establishment.

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