**6. How should coping intelligence be incorporated into existing emotional intelligence training?**

The process of integrating CI into existing EI training paradigms can be challenging. First, trainees should be introduced to, and become proficient in, EI itself. This provides a solid foundation for the subsequent discussion and incorporation of CI as a meta-layer that functions as a 'safety valve' on top of EI (**Figure 3**). It is important to note that EI is a powerful moderator of coping strategies and perceived service outcomes, especially in situations where service failure (e.g., inability to deliver services as promised) is present [50]. This is indeed a common scenario within the functional realm of a graduate medical education (GME) trainee.

#### **Figure 3.**

*Simplified diagram showing the ability to transition from "routine" emotional intelligence (EI) skillset to a "more specialized" coping intelligence skillset can be viewed in the context of escalating levels and complexities of stress.*

Second, those who made sufficient progress in their EI training (as evidenced through significant improvement on repeat standardized EI assessment tools) should be gradually introduced to the concept of CI. Experience-based group discussions are well suited toward increasing one's awareness that the ability to handle emotions under 'normal circumstances' has its limits, and that despite one's best efforts there are instances where 'extreme pressure' may result in loss of emotional control (**Figure 3**).

Current hospital policies and procedures that help providers/trainees deal with 'extreme pressure' in medicine tend to be retrospective in orientation, although there are programs that incorporate prospective measures to improve coping. An example of this is obstetrical hemorrhage. The stress of managing obstetrical hemorrhage can take clinicians and staff from problem-based coping to emotionbased coping in a matter of minutes, compounding errors and potentially leading to devastating outcomes for patients and providers [51]. In the typical scenario, these cases are extensively discussed after the fact using mechanisms such as intense analysis and morbidity and mortality (M&M) conferences [52–54]. These are protected conferences that are meant to highlight quality and safety considerations while also acting as experience-based educational group discussions. Focus on process can build problem-oriented coping skills for future traumatic events.

Many residency training programs have taken a proactive approach to enhance problem-based coping and minimize emotion-based coping. In obstetrics, this is achieved through post-partum hemorrhage drills and group training that can reduce post-partum hemorrhage [55–57]. Adherence to guideline-based care and check-lists can also enhance problem-based coping [58, 59]. This, in turn, facilitates improved coping at the individual level. Although rigorous training (drills) and adherence to checklists can help enhance problem-based coping, there will always be situations that can appear hopeless to the provider/trainee. Preparing trainees to cope more effectively with highly stressful and potentially chaotic situations, such as the management of maternal hemorrhage, will be an important aspect of addressing the need for better overall management of the 'emotional burden' associated with low-frequency, high-impact clinical events [60, 61].

GME programs can turn to other strategies to mitigate stress and anxiety. Dedicated support programs were originally initiated to reduce symptoms of burnout: depersonalization, emotional exhaustion, and diminished sense of personal accomplishment. At the same time, tools that can reduce stress and anxiety may also help enhance efficient coping. Mindfulness training programs have been demonstrated to be feasible – even among the most demanding residency programs [62]. For example, implementing a mindfulness-based cognitive training program for surgical residents showed improvement in perceived stress and interestingly may

#### *Facing Adversity during Graduate Medical Training: The Concept of 'Coping Intelligence' DOI: http://dx.doi.org/10.5772/intechopen.99698*

have resulted in improved technical skills [63]. In another example, when a broadbased curriculum including mindfulness training was applied to intensive care unit (ICU) providers, there were fewer patient safety events [64].

GME programs can promote efficient coping by enhancing problem-based coping and mitigating the effects of inefficient emotional coping through programs that can reduce stress and anxiety. Running drills for high-stress situations, developing and adhering to guidelines/quality bundles and checklists are all practical methods for improving providers' and trainees' problem-based coping [65–67]. The overall goal should be to provide tools to reduce the immature coping mechanisms that can occur in high-stress situations (**Table 1**). Mindfulness programs have been effectively instituted and can help mitigate the over-reliance on emotion-based coping. Taking a prospective approach to coping is likely to have a greater effect than retrospective, peer-protected group discussions such as M&M conferences.
