Physician Wellness Mindfulness in Medicine

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Physician WellnessMindfulness in Medicine

• Aleksandra Zgierska, MD, PhD
• Primary Care Faculty Development Fellowship
• University of Wisconsin, School of Medicine and
  Public Health, Department of Family Medicine
• Madison, WI, Nov 12, 2010

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Department of Family Medicine
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Physician Wellness

• High quality of care delivered
• Job satisfaction ? stability of workforce
• Personal quality of life / family life
• Life Balance

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When wellness is compromised physician burnout

• Emotional exhaustion
• Depersonalization (treating patients as objects)
• Low sense of accomplishment
• Increased stress

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Consequences of Burnout

• ? quality of life
• ? quality of care
• ? sense of accomplishment
• Life / work dissatisfaction
• Instability of workforce
• Divorce
• Depression suicide
• Addiction

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Primary care

• An alarming number of physicians, unable to cope
  with the pressures of practicing everyday
  medicine, succumb to the stress. Consider that
  300-400 doctors in the U.S. kill themselves every
  year, or roughly 1 per day. Male doctors have
  suicide rates 1.4 times that of a general
  population, while female doctors have twice the
  rate of depression and 2.3 times the suicide rate
  when compared with women who are not physicians.
• Help for Todays Tense, Frustrated Doctors,
• K. Pho, D. Farrago, Medscape Business of
  Medicine, 10/26/09

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Primary care

• Surveys of PCPs
• up to 60 of practicing physicians report
  symptoms of burnout, in part due to worsening
  time pressures and a chaotic work pace, which
  were strongly associated with low physician
  satisfaction
• Maslow Burnout Inventory
• Linzer et al, Ann Intern Med, 2009, 151
  28-36
• Spickard et al, JAMA 2002, 288 1447-50
• Shanafelt et al Am J Med, 2003, 114 513-19.

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Pathophysiology of Burnout

• Burnout may be related to lack of sense of
  control and loss of meaning
• Dunn et al, J Gen Intern Med, 2007, 22
  1544-52
• Study of physicians found that the capacity of
  being present with their patients correlated
  more strongly with finding meaning in their work
  than diagnostic or therapeutic successes.
• Horowitz et al, Ann Int Med, 1995, 138
  772-76.

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Prevention / Treatment of Burnout

• Lack of standardized treatment
• Lack of system-wide approaches

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Prevention / Treatment of Burnout

• Enhancing Meaning at Work
• a Prescription for Preventing Physician Burnout
  and Promoting Patient-Centered Care.
• Shanafelt TD, JAMA, 2009, 3021338.

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Prevention / Treatment of Burnout

• New initiatives.
• One possible approach to address loss
• of meaning and feeling of lack of control
• is through developing greater mindfulness
• AAFP News Now 'Mindful Communication' Can Help
  Physicians Deal With Burnout, Says Study.
• www.aafp.org/online/en/home/publications/news/n
  ews- now/professional-issues/20091109mindful-com
  m.html
• 11-2009

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What is Mindfulness Meditation ?

• Originated in many ancient religions/cultures
  across the world

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Mindfulness Meditation (MM)

• Popularity has been
• growing
• As a therapy, it
• is already used
• in clinical settings

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Meditation

• meditation technique of an intentional
  regulation of attention
• ?
• focus on the present moment
• ?
• autopilot

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Mindfulness

• the way we pay attention
• to the present moment
• on purpose, non-judgmentally,
• with acceptance
• with openness, curiosity, kindness
• practiced by using meditation

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Mindfulness Meditation

• being in the present moment
• better recognition of thought patterns,
• emotions, sensations
• ? mindful response (vs. autopilot)
• helps act reflectively (non-judgmentally) rather
  than impulsively

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Mindfulness Meditation therapy

• mental health problems
• stress, anxiety, depression, ADHD,
• borderline personality disorder,
• sleep problems, bulimia
• addictive disorders
• cardiovascular disorders
• other chronic conditions obesity, psoriasis,
  diabetes, cancer, AIDS

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Personal Growth and Well-being Long-term
Practitioners

• Buddhist monks (R. Davidsons studies)
• ? gamma brainwave activity suggesting
• ? intelligence
• ? compassion
• ? self-control
• ? happiness

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Personal Growth and Well-being Healthy
Individuals

• Meta-analysis (10 studies) evaluating effects of
  mindfulness training
• ? stress
• ? ruminative thinking
• ? empathy
• ?compassion
• ? spiritually
• ? quality of life

Chiesa A, J Altern Complement Med, 2009
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Personal Growth and Well-being

• After Mindfulness training
• ? antibody titer after flu shot
• ? positive emotions
• brain imaging studies biological
• changes (? prefrontal cortex, ? amygdala
  activity)
• Improved stress biomarkers
• cortisol, cytokines

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Health Care Providers

• After Mindfulness training,
• nursing, pre-med medical students
• ? empathy
• ? stress
• ? anxiety

Shapiro SL, J Behav Med 1998
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Primary Care Physicians (N70)

• 15 months after Mindfulness training
• ? burnout
• ? perceived stress
• ? stress coping
• ? emotional stability
• ? empathy
• ? sustained well-being
• ? attitude toward patient care

Krasner MS et al., JAMA 2009, 302 1284-93
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Health Care ProvidersBetter Treatment Outcomes

• RCT of mental health providers
• Mindfulness training vs. not
• Trained providers had better mental health
  treatment outcomes
• in their patients

Grepmair L, Psychother Psychosom 2007
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Mindfulness in Medicine

• benefits for providers AND patients
• life-long effects transferable skills
• high client satisfaction
• no side effects
• non-stigmatizing
• ? cheap

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Mindfulness in Medicine

• Mindfulness
• is a discipline and an attitude of mind
• its practice requires mentoring and guidance.
• can link evidence-based and relationship-center
  ed care and help to overcome the limitations of
  both approaches.
• should be considered a characteristic of good
  clinical practice
• Epstein RM Mindful Practice, JAMA 1999

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Why Mindfulness ?Personal professional
journey

• Secular or religious flexible
• Better life
• equanimity, happiness
• stress management
• life-long skills
• not a therapy
• Better services as a provider

• Hokusai, Big Wave

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MM-based therapies

• Vipassana meditation
• Mindfulness Based Stress Reduction, MBSR
• Mindfulness Based Cognitive Therapy, MBCT
• Mindfulness Based Relapse Prevention, MBRP
• Dialectical Behavior Therapy, DBT
• Acceptance Commitment Therapy, ACT
• Spiritual Self Schema, 3-S

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Vipassana meditation

• the most traditional approach
• retreats (many - silent)
• 10-day Vipassana (www.dhamma.org)
• varied duration Insight Meditation
• (www.dharma.org)

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Mindfulness Based Stress Reduction, MBSR

• UMass (Center for Mindfulness in Medicine, Health
  Care, and Society)
• Mindful Leadership Program
• Retreat Cultivating Leadership Presence through
  Mindfulness (good !!!)
• next year in WI
• by invitation / application

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MBSR

• UW-Madison Integrative Medicine
• Dave Rakel, MD
• Research on preventing / treating burnout
• Meditation study for PCPs
• meditation course is free (PCPs are paid !) and
  abbreviated, with weekend / evening schedule
• brochures available
• waiting lists for both

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Mindfulness Based Cognitive Therapy, MBCT

• Designed for relapse prevention in depression
• http//www.mbct.com
• book The Mindful Way Through Depression
• Strong evidence for depression, anxiety
• Andrew Moore, MD, WISPIC (UW Psych)
• courses designed for depression or anxiety
• most insurers cover them 100 !

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Mindful Eating

• The Center for Mindful Eating (TCME)
• http//www.tcme.org
• 4 Easy Ways to Prevent Mindless Eating Simple
  tips you can use to stop the unconscious
  munching. No diet required.

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Other resources

• Lee Lipsenthal, MD
• Book "Finding Balance in a Medical Life".
• AAFP video Living and Dying with Balance.
  (www.aafp.org/online/en/home/cme/aafpcourses/confe
  rences/assembly/cme/plenaries0.html)

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Other resources

• UW DFM MBSR website
• Mindfulness in Medicine http//www.fammed.wisc.edu
  /mindfulness
• UW MBSR ?
• For Health Professionals

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Mindfulness in daily life

• Pause
• Presence
• Proceed

- stop, take a breath, drop in
- be aware of what is happening now body
sensations, thoughts, emotions open to what is
here observe (accept) what arises for you just
as it is, moment by moment, without reactivity.
Listen deeply.
- Whats called for NOW? - use mindful
speech and action to respond compassionately,
and with positive intention. Adapted from
www.fammed.wisc.edu/mindfulness
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Thank you !

• Aleksandra.Zgierska_at_fammed.wisc.edu