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MINDFULNESS
IN
MEDICAL EDUCATION
Millaray Sanchez-Campos and Douglas Archibald Department of Family Medicine
ADAPTED FOR the Annual DFM Retreat Montebello, QC September 20, 2014
Acknowledgments
Carol Gonsalves MD, FRCP (C), MEd Diana Koszycki PhD Heather MacLean MD, FRCP(C) Veronique Duschesne MD Candidate Class 2016 Kay-Anne Haykal MD, CCFP
DISCLOSURE
The following presentation is free from bias and the presenters are not affiliated with any for-profit organizations or parties.
The presenters do not have any conflict of interests to disclose and are not affiliated with any commercial entities or organizations that serve to profit from this presentation.
FACULTY/PRESENTER DISCLOSURE
• • • •
Faculty: Dr. Sanchez-Campos and Dr. Archibald Relationships with commercial interests: None Disclosure of Commercial Support: N/A Mitigating Potential Bias: N/A
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WORKSHOP OBJECTIVES
To understand the scientific evidence about the importance of incorporating mindfulness in medical education (undergraduate, graduate and CPD) For clinical teachers in the DFM to learn about the UGME mindfulness curriculum at the University of Ottawa To provide an introduction to mindfulness practice and how it can help in building resilience
OUTLINE
Introduction Discussion 15 minutes Practicing Mindfulness 15 Minutes Mindfulness in Medical Education 10 minutes 10 minutes
OUR MODERN LIFE
PHYSICIAN HEALTH
BEING IN THE MOMENT...
What is Mindfulness
Jon Kabat-Zinn Paying attention on purpose In the present moment Non judgementally
WHAT IS MINDFULNESS
" The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will. . . An education which should improve this faculty would be the education par excellence" William James, Principles Of Psychology, 1890
SCENARIO “DO OVER”…MINDFULLY
Medicine: The facts
Physician Distress
• Burnout in 30-60% of specialists and GP • More prevalent in private practice (55%-67%) than academic faculty (37%-47%) • Medicine associated with burnout, depression, anxiety, substance abuse, divorce and broken relationships Shanafelt et al. The Well-Being of Physicians. The American Journal of Medicine. 2003;114:513-519
BURNOUT AND MEDICAL ERRORS
• Of the 7905 American College Surgeons, 700 (8.9%) reported concern they had made a major error in last three months • Over 70% attributed error to individual factors Shanafelt et al; Burnout And Medical Errors Among American Surgeons. Ann. Sur 2009
BURNOUT AND SELF REPORTED CARE
• Of 115 (76%) responding residents, 87 (76%) met the criteria for burnout (Maslach Burnout Inv.) • Burnout residents were significantly more likely to self report suboptimal patient care at least monthly (53% vs. 21%; P=0.004).
Shanafelt et al. Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program. Ann Inter Med. 2002; 136:358-367
EMPATHY IN MEDICAL SCHOOL
• Medical students from a university-based medical school surveyed yearly from 2007 through 2010, using Jefferson Scale of Physician Empathy-Student Version (JSPE-S) • Empathy scores of students in pre-clinical years were higher than in clinical years • Gender was a significant predictor of empathy, women > men Chen et al. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34(4):305-11
MINDFULNESS PRACTICE ON STUDENT STRESS LEVEL
• 66 med. students in their clerkship at University of Tasmania • Randomized to intervention, 30 min audio CD of guided mindfulness practice and a control group • Self-report PSS (Perceived Stress Scale) and DASS (Depression, Anxiety and Stress Scale) at baseline and 8 wks.
Warnecke et al. A Randomized controlled trial of the effects of mindfulness practice on medical student stress levels. Medical Education 2011:45:381-388
MBSR AND CHANGES IN GREY MATTER
Memory process Emotion regulation Self-referential processing Perspective taking Holzel et al. Mindfulness Practice leads to increases in regional brain grey matter density. Psychiatry Res. 2011 January 30; 191 (1): 36-43
MINDFUL COMMUNICATION IN PCP
• 70 Primary care physicians enrolled in CME in Rochester, NY. 8-wk course, 2.5 hours/wk. , a 7 h retreat, followed by a 2.5 h/mo x 10-month.
• Improvement in burnout, empathy, mindfulness, total mood disturbance and personality.
• Improvements in mindfulness were correlated with improvements in all other measures.
Krasner, M, Epstein, R et al. Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians. JAMA, 2009; 302(12):1284-1293
SELF-MONITORING IN CLINICAL PRACTICE
• Self-monitoring as an important component of the professional competence of physicians • It allows early recognition of cognitive biases • Avoidance of technical errors • Awareness of emotional reactions • Facilitates self-correction • Development of therapeutic relationships Epstein R. Mindful Practice in Action (II): Cultivating Habits of Mind. Fam Syst Health 2003:21:11-17
MINDFULNESS CURRICULUM
MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE
• 2012: A-pilot project of « Mindful Practice in Clinical Practice » was added as a teaching innovation to the 3rd year rotation in Family Medicine.
• PIME grant awarded to study this teaching innovation. Research is in progress.
• 2013-2014 class evaluations are very positive:
MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE
• definite eye opener • truly enjoyed • excellent • Interesting • insightful, • relaxing, • important to teach in the curriculum
MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE
• will try to make sure I use it in the future • it prompted me to be present in my everyday life, will use in the future to relieve stress • will definitely try to implement some of the mindfulness technique in my work and daily routine • now I try to be mindful before doing things
MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE
The session was well run and well led. This being said, it was time wasted. A mindfulness workshop is a great thing to offer to medical students outside of academic time. As a mandatory portion of our academic teaching, it is nothing short of a farce. Instead of choosing from a myriad of useful topics to teach from any area ranging from clinical medicine to pharmacology, I spent my academic morning eating a raisin and contemplating its texture. This is nonsense. In my opinion, this time should be spent on topics that will enrich our knowledge and performance as physicians
MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE
Importance of incorporating a “Mindful Practice “ curriculum in medical schools Sep 2014 will commence a 2-year Mindfulness Curriculum for pre-clerkship at uOttawa To be linked with workshop in mindfulness given in 3 rd similar workshops in postgraduate programs in the future year FM rotation with anticipated Possibility to be linked with an online-MBSR program
OTHER FACULTIES OF MEDICINE
Canadian: McGill University, Montreal: Mindful Medical Practice (Drs. T. Hutchinson, Dobkin): Students; University of Toronto: Students/Residents; University of Alberta, Edmonton - Residents Monash University (Australia):Health Enhancement Program (Dr. C. Hassed) University of Rochester (NY): Mindfulness Curriculum for Clerkship (Drs. Krasner, Epstein) University of Massachusetts (MA): The Contemplative Mind In Medicine (Drs. Santorelli and Kabat-Zinn) Other electives throughout US, UK, Germany
STARTING A MINDFULNESS PRACTICE
• Stop-breath and be: Take few moments during the day to take 3-5 breaths, before starting a new activity and/or seeing a new patient • 2-5 minutes of sitting meditation in am-hs • Stop and breath at red/yellow lights • Practice walking meditation • Practice mindful listening
STARTING A MINDFULNESS PRACTICE
• Practice mindful eating/drinking for few minutes • Use background noise to stop and take three breaths • Breathe 3-5 times before getting up and at bedtime • Being mindful when working out • Bringing mindfulness to everyday activities
RESOURCES
Guided meditation: www.mindfulselfcompassion.org
Mindfulness meditation as a tool for compassion fatigue: https://compassionfatigue.ca
RESOURCES
Modern Meditation Mindfulness Resources
http://www.modernmeditation.ca/mindfulness resources/
RESOURCES
• Kabat-Zinn, Jon. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion, 1994.
• • Kabat-Zinn, Jon. Full Catastrophe Living.
Bantam Dell. New York. 1991.
• Tolle, Eckhart. The Power of Now. Novato, CA: New World Library, 1999.
• Hanh, Thich Nhat. You Are Here. Boston: Shambhala Publications, 2001.