Transcript 1-Mindfulness-in-Med..

Mindfulness in MedicinePractical 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
[email protected]
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/
191888/2013physiciantrends-void_ebk0513.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/DcomUnitedStates/Local%20Assets/Documents/us_chs_2013Surv
eyofUSPhysicians_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/de
fault/Physicians_Foundation_2012_Biennial_Surve
y.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/Document
s/White%20Papers/Wolters%20Kluwer%20Health%20P
hysician%20Study%20Executive%20Summary.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/compensati
on/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
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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 E1-E11
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
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 goalsTo 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
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 ofTaking 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 handsRubbing palms until warm
Placing palms over eyes
Using fingertipsMassage face, neck and shoulders
Contemplating hands againRecalling how they have been used in healing
Imagining how they will be used for healing
Healing ourselves, healing our patients