Mindfulness in Medicine Practical tools for physician selfcare

Mindfulness in Medicine. Practical tools for physician self-care and patient care John A. Patterson MD, MSPH, FAAFP KAFP Annual Scientific Assembly November 2014 Mind Body Studio 517 Southland Drive Lexington KY 859 -373 -0033 john@mindbodystudio. org

Objectives After this presentation, you will be able to • Define mindfulness and mindful practice • Relate mindful practice to the Hippocratic ideals of family medicine • Describe how you can use mindfulness to prevent burnout and cultivate compassion • Understand how mindfulness can enhance the physician-patient relationship • Recognize the relevance of the University of Rochester School of Medicine’s Mindful Practice curriculum • Appreciate the clinical application of mindfulness in managing stress-related chronic disease • Incorporate a set of simple mindfulness practices into your personal life and professional work

Professional Quality of Life Scale PROQOL • Compassion satisfaction scale • Burnout scale • Secondary traumatic stress scale What’s your score?

Filling the Void – 2013 Physician Outlook and Practice Trends http: //www. jacksonhealthcare. com/media/ 191888/2013 physiciantrends-void_ebk 0513. pdf “Physician discontent appears to be creating a void in the healthcare field. Physicians are preparing to leave medicine early either through retirement or a change in their career field. Those that remain in practice feel disconnected from their patients… Top 3 reasons cited for leaving medicine in 2013 1) Burnout (60%) 2) Don’t want to practice in era of healthcare reform (58%) 3) Economic factors such as malpractice insurance, overhead, EMR, etc (50%)”

Deloitte 2013 Survey of US Physicians- Physician Perspectives About Health Care Reform and the Future of the Medical Profession http: //www. deloitte. com/assets/Dcom. United. States/Local%20 Assets/Documents/us_chs_2013 Surv eyof. USPhysicians_031813. pdf “Nearly 6 in 10 physicians… are concerned about the future of medicine, pointing to declining clinical autonomy and income. Pessimism among physicians resulted in nearly 75% agreeing that "the best and brightest" may avoid a career in medicine… Still, 7 in 10 physicians reported they were satisfied with their careers. The most satisfied… were the nonsurgical specialists (67%) and physicians aged 25 to 39 (80%). Primary care physicians were the least satisfied…at 59%. ”

A Survey of America’s Physicians: Practice Patterns and Perspectives http: //www. physiciansfoundation. org/uploads/d efault/Physicians_Foundation_2012_Biennial_Sur vey. pdf “Over half of physicians surveyed have reached a tipping point and plan to make changes to their practices. Many intend to take one or more steps likely to reduce patient access to their services, limiting physician availability at a time when doctors already are in short supply. ”

Wolters Kluwer Health 2013 Physician Outlook Survey http: //www. wolterskluwerhealth. com/News/Documen ts/White%20 Papers/Wolters%20 Kluwer%20 Health%20 P hysician%20 Study%20 Executive%20 Summary. pdf More than one-third of physicians say they are likely to leave their practice in the next 1 -2 years, including 15% who are very likely to do so. The top two reasons for leaving among all physicians surveyed is that it is hard to make practice profitable and time to retire. Not surprisingly, those who have been practicing more than 20 years say the top reason is time to retire versus those who have been practicing 20 years or fewer, who cite difficulty in making their practice profitable.

Medscape Physician Compensation Report 2014 http: //www. medscape. com/features/slideshow/compensat ion/2014/public/overview specialists who ranked among the highest paid in 2013 reported the lowest levels of satisfaction with the profession. For example, anesthesiologists, radiologists and orthopedists… Among the three specialties, the percentage who said they would still choose to go into medicine if given a second chance ranged from 44 percent to 47 percent. Conversely, 67 percent of family physicians said they would choose medicine again as a career. Yet despite being satisfied with the medical profession overall, the survey indicated they do not feel the same about their specialty. Only 32 percent of family physicians said they would stay in the same medical specialty.

Signs and Symptoms of Burnout Physical and emotional exhaustion Cynicism and detachment A sense of ineffectiveness Overidentification or overinvolvement Irritability, hypervigilance, sleep problems Social withdrawal Poor judgment Perfectionism Kearney JAMA 2009

Signs and Symptoms of Burnout Questioning the meaning of life Questioning prior religious beliefs Interpersonal conflicts Avoidance of emotionally difficult clinical situations Addictive behaviors Numbness and detachment Difficulty in concentrating Frequent illness: HA, GI disturbances, immune system impairment Kearney JAMA 2009

Burnout “Hallmark Symptom” A loss of interest in one’s work and personal life and a feeling of “just going through the motions”

Measures that may help prevent burnout • • • Mindful meditation Reflective writing Training in communication skills Development of self-awareness skills Practice of self-care activities Kearney JAMA 2009

Mindfulness benefits for patients Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress (anxiety, depression and pain)… be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress. Stronger study designs are needed to determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior. Goyal M, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Internal Medicine Published online January 6, 2014, pp E 1 -E 11

What is mindfulness? Paying attention, In the present moment, On purpose, Non-judgmentally, As if your life depended on it Jon Kabat-Zinn Founder, Center for Mindfulness in Medicine, Health Care and Society, Creator of Mindfulness-Based Stress Reduction MBSR

What is mindfulness? The capacity for lowering one’s own reactivity (paying attention to experiences without reacting to them) The ability to notice and observe sensations, thoughts and feelings even though they may be unpleasant Mindful Practice curriculum, U Rochester School of Medicine

What is mindfulness? Acting with awareness and intention (not being on automatic pilot) Focusing on experience, not the labels or judgments we apply to them (feeling an emotion rather than wondering if it is OK to feel that emotion) Mindful Practice curriculum, U Rochester School of Medicine

What is mindfulness? A naturally occurring human experience that can be approached in many ways including a variety of meditation traditions, sports and physical activity, educational methods, nature, creative expression, music, pets, babies, crocheting, etc Learners are encouraged to find their own methods for cultivating mindfulness in their daily lives Mindful Practice curriculum, U Rochester School of Medicine

What is mindfulness? We propose a two-component model… The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment. The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness and acceptance. Bishop SR, et al, Mindfulness: A Proposed Operational Definition Clinical Psychology: Science and Practice, 11, 3: 230 -241: Autumn 2004

Mindfulness Mechanisms of Action Possible mechanisms- (1) decreased perception of pain severity (2) increased ability to tolerate pain or disability (3) reduced stress, anxiety, or depression (4) diminished usage of, and thereby reduced adverse effects from analgesic, anxiolytic, or antidepressant medication (5) enhanced ability to reflect on choices regarding medical treatments (6) improved adherence to medical treatments (7) increased motivation for lifestyle changes involving diet, physical activity, smoking cessation, or other behaviors; (8) enriched interpersonal relationships and social connectedness (9) alterations in biological pathways affecting health and its systems. Ludwig, D. S. , & Kabat-Zinn, J. (2008). Mindfulness in medicine. Journal of the American Medical Association, 300, 1350 -1352.

Primary Care Physician Mindfulness Intervention Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient centered care Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians Krasner MS JAMA. 2009, 302(12), 1284 -1293

Mindful Exercise • Mindful communication in dyads • Consider how you have allowed your work to take priority over something you value highly, such as creativity, passionate avocations or self care • Describing this to your dyad partner, explain your regrets and strategies for reclaiming your wholeness as well as your feelings and emotions about this selfneglect • Speak knowing your partner will only listen • Pay attention to sensations, thoughts and emotions • The bell will signal time to switch

Cultivating Mindfulness in Health Professionals There exists an impetus for the development of curricula aimed at fostering wellness and selfcare skills for clinicians. Review of the empirical evidence suggests MBSR programs aimed at enhancing well-being and coping with stress yield benefits for clinicians in the domains of physical and mental health Cultivating mindfulness in health care professionals: A review of empirical Studies of mindfulness-based stress reduction (MBSR) Irving, Complementary Therapies in Clinical Practice 15 (2009) 61– 66

3 Components of MBSR Mindfulness Based Stress Reduction 1) Mindful yoga 2) Mindful body scan 3) Mindfulness meditation Breathing Sitting Walking Eating Speaking and Listening Formal and Informal Practice

Mindful Exercise Mindful Eating Contemplative Eating Meditation “Raisin Meditation”

University of Wisconsin School of Medicine and Public Health Department of Family Medicine Mindfulness in Medicine Program Improving Clinician and Community Health • A 3 Step Exploration of Health: Practice in Your Practice • Incorporate these three mindfulness steps in to your daily life or clinical practice: 
 1. Pause 2. Presence, 3. Proceed

Mindfulness for Family Physicians Mindfulness training adapted for primary care clinicians was associated with reductions in indicators of job burnout, depression, anxiety, and stress. Modified mindfulness training may be a time-efficient tool to help support clinician health and well-being, which may have implications for patient care. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians: A Pilot Study Fortney, L. et al, Ann Fam Med 2013; 412 -420

Mindful Exercise Mindfulness of the body While sitting still While moving Head, neck, shoulders, arms, spine Tensing and relaxing muscles Mindfulness of the breath

A Curriculum in Mindful Practice U of Rochester School of Medicine and Dentistry Focused on cultivating mindfulness during clinical work settings with 2 interrelated goals. To improve the quality of care To improve physician well-being

ACGME Competencies • Reducing medical errors • Improving caring attitudes and professionalism • Furthering professional competence Patient care Communication/Interpersonal skills Practice-based learning Systems based practice

A Curriculum in Mindful Practice Develop 4 Attributes of Exemplary Physicians Attentive Observation Critical Curiosity Informed flexibility (Beginner’s Mind) Presence

Attentive Observation Observing without making judgments that distort or diminish one’s understanding Involves monitoring one’s own biases, thoughts and emotions: “Witnessing the observer observing the observed”

Critical Curiosity Opening up to possibilities rather than premature closure and discarding disconfirming data “Jumping to conclusions, snap judgments”

Informed Flexibility “Beginner’s Mind” Addressing the mind’s tendency to take only one perspective on a problem By allowing a fresh perspective and taking more than one perspective simultaneously, more diagnostic and therapeutic options open up

Presence Involves being there physically, mentally and emotionally for patients, and accurately communicating an understanding of the patient’s concerns and feelings back to the patient (empathy) Student narratives on “being there” in a noisy, fast paced, stressful hospital environment are shared, making their strategies more generally adopted

Hippocratic Ideals • Primum non nocere – First, do no harm Non-maleficence • Beneficence- kindness, compassion • Professionalism, art and science • Service, mission • Relationship, covenant • Communication /listening • Health promotion • Whole person perspective

Mindful Self Compassion Self-compassion is conceptualized as containing 3 core components: self-kindness versus self- judgment, common humanity versus isolation, and mindfulness versus overidentification, when relating to painful experiences. Research evidence demonstrates that self-compassion is related to psychological flourishing and reduced psychopathology. Mindful Self-Compassion (MSC) is an 8 -week training program, meeting 2. 5 hours each week, designed to help participants cultivate self-compassion. MSC contains a variety of meditations (e. g. , loving-kindness, affectionate breathing) as well as informal practices for use in daily life (e. g. , soothing touch, self-compassionate letter writing). Self-Compassion in Clinical Practice Germer C. , Neff K. J Clin Psych: In Session, 69(8), 856– 867 (2013)

Mindful Cultivation of Gratitude… incorporating not only the gratitude that arises following help from others but also a habitual focusing on and appreciating the positive aspects of life… Gratitude is strongly related to well-being, however defined, and this link may be unique and causal. Interventions to clinically increase gratitude are critically reviewed, and concluded to be promising…a distinct research strategy is suggested. Gratitude is relevant to clinical psychology due to (a) strong explanatory power in understanding well-being, and (b) the potential of improving well-being through fostering gratitude with simple exercises. Wood A. M. (2010) Gratitude and well-being: A review and theoretical integration. Clin Psych Review, 30 (7), 890 -905

MBSR inclusion/exclusion criteria Inclusion criteria • Any physical, emotional or mental condition adversely affected by stress • To enhance awareness, coping skills, resiliency, focus • To develop healthier interpersonal patterns • To enhance attunement with mind and body Examples of conditions referred – Chronic pain, fatigue, stress, mild/moderate depression and anxiety, ADD, chronic PTSD, disturbed sleep, functional GI disorders, living with chronic or life-threatening conditions Exclusion criteria • Lifestyle issues (language, active substance dependency) • Psychological issues (suicidal, psychosis, acute/subacute PTSD, social anxiety, severe depression) • Those in chemical recovery less that a year- deemed to be possible relapse candidates due to the nature of introspective work. • Those with fragile emotional status from whatever cause- trait or state • Attitudinal issues (“quick fix”, attendance) • Physical issues (attendance) Exceptions exist on a case by case basis

What about monotheistic religions? All religions have a contemplative (mystical) tradition which has been obscured over time for many reasons Mystical- direct subjective experience of spiritual meaning Judaism- kavanah, musar, kaballah, visualization, intuitive methods and emotional insight in prayer Islam- zikr, Sufism, prayers remove the 10, 000 veils one at a time Christianity- lectio divina, ‘still small voice’, ‘be still and know’, ‘kingdom of heaven is within’, ‘temple of the Holy Spirit’, Centering Prayer

Mindfulness in Pastoral Care Though mindfulness comes from Buddhist background he has adapted it to his own faith tradition 30 minute daily practice session consists of. Taking my seat aware of breath and posture Aware of body sensations Aware of the flow of thoughts Aware of feelings, mood and tone Aware of enlarging open spaces between thoughts Mindfulness Practice Neth, J of Pastoral Care and Counseling, Spring-Summer 2008 v 62, no 1 -2, 143 -144

Mindfulness in Your Workday Take half a minute of silence Before going into the next patient’s room, pause and bring your attention to the sensation of your breathing for 2 to 5 breaths Use the suggested 20 seconds of hand washing in creative ways, pay attention to the sensation of the water on your skin and allow yourself to sink into this experience; make this an act of conscious receiving by acknowledging to yourself “I am worthy of my own time” Self-care of Physicians Caring for Patients at the End of Life: “Being Connected. . . A Key to My Survival” Kearney MK et al, JAMA 2009, 301(11), 1155 -64

Mindful Reflection Contemplating hands. Rubbing palms until warm Placing palms over eyes Using fingertips. Massage face, neck and shoulders Contemplating hands again. Recalling how they have been used in healing Imagining how they will be used for healing Healing ourselves, healing our patients