**3. Coping intelligence: a logical extension of emotional intelligence?**

Concepts such as 'Emotional Intelligence' (EI) have been introduced into the area of GME some time ago, and although significant progress has been made in promoting and implementing the much needed change across various medical education settings, there remains an unaddressed behavioral niche that does not seem to fit the 'standard descriptors' and 'routine situations' encountered under high-stress, 'zero-sum game' clinical scenarios or 'no-win' situations [6, 10]. Consequently, the much dreaded phenomenon of physician and trainee burnout (using the definition from Korunka et al. [21].) continues unabated, despite the above efforts to enhance individual ability to cope with the combined macrotrauma of major clinical and life events, combined with the repeated microtrauma of multiple stressful events across different domains of life.

Within this overall context, it is becoming increasingly evident that EI simply stops being effective above a certain – likely highly individualized – threshold of stress and cognitive loading. At that point, no matter how well someone can handle themselves within a 'normal set of circumstances,' loss of emotional control becomes much more likely. As emotional control is lost, one's coping approaches transition from more mature defense mechanisms to increasingly immature defenses (**Table 1**), and he or she is more likely to commit judgment errors and/or become engaged in maladaptive behavior patterns. If the above is indeed the case, how can the awareness of (and training in) CI help one avoid the potentially disastrous emotional 'loss of balance'? Of additional importance to patient safety and patient well-being is the question that we must ask in this context, "what is the effect of the provider's or trainee's emotional state on bedside care?"

#### **4. Current understanding of coping approaches**

Literature focusing on individual coping with life difficulties provides limited answers and/or practical solutions [20]. Under the general umbrella term "coping," there are two subdomains – applied problem solving [22, 23] and coping with stress [24]. Early work published by Lazarus and Folkman categorizes coping as either problem-oriented or emotion-oriented [24]. At a more granular level, problemfocused coping is centered on managing and/or regulating a stressful scenario (e.g., when "something can be done") [20]. On the other hand, emotion-focused coping is used to modulate emotional response to a stressor (e.g., when "nothing can be done") [20]. Important within the broader context of CI is the role of problem solving competence through attitudes and belief systems [24, 25]. More recently, combined approaches began to emerge, based on the assumption that the perceived problem-solving effectiveness can be regarded as the degree to which one's actions promote or impede progress toward a resolution of the problem at hand [23].

Essentially, in academic systems, overall levels of stress are generally higher when compared with other areas within the fabric of our society [26–28]. Both professional and social complexities associated with a typical academic position, regardless of whether one's role is a trainee or a teacher, can be overwhelming and may lead to burnout [10, 11, 29, 30]. Additional socioeconomic and diversityrelated considerations may also be important in this context [31, 32], and various forms of academic networking appear to be helpful as an approach to ameliorate the demands and overall stress of an academic career [33, 34]. Engagement within a social network may bring some advantages in terms of both greater resiliency and better coping skills [35–37].


