Prior to considering any intervention in physician wellness, it is important to reiterate the complexity of the issue and acknowledge the multiple metrics of success required for professional fulfillment and avoidance of burnout. Concisely delineated by Shanafelt et al at Stanford they include:
- Developing a ‘culture of wellness’ (leadership, value alignment, sense of community at work, feeling of appreciation and being heard)
- Efficiency of practice (electronic health records, team-based care, scheduling, triage)
- Personal resilience (self-care, compassion, meaning in work, work-life integration, emotional flexibility) (Shanafelt et al)
Institutional and organizational factors are of critical importance in burnout prevalence
Accruing research has shown that institutional and organizational factors are of critical importance in burnout prevalence, these will be covered in future columns. The message of this column is that although addressing personal resilience alone is not sufficient to resolve the complex issue of burnout in medicine, mindfulness is a promising tool for individuals to explore.
The unexpected juxtaposition of mindfulness as both an ancient meditative practice and a powerful tool to mitigate physician burnout may surprise physicians who are classically trained to separate spirituality and medicine. This column will describe and address the utility of mindfulness and offer a brief update on how it can be applied in a variety of clinical settings.
Research on mindfulness was initially introduced into mainstream medicine by Kabat-Zinn, Ph.D., in the late 1970s in a program for patients living with chronic pain, often in the form of a mindfulness-based stress reduction (MBSR) course. This is typically taught as an 8-week program that combines a variety of mind-body therapies such as breath work, progressive muscle relaxation, mindful eating, mindful movement, yoga, and meditation to introduce the concept of mindfulness in such a way as to allow people with a range of skills and awareness to access the material and learn to apply it in a wide range of clinical conditions and settings.
Kabat-Zinn has described mindfulness as ‘paying attention with moment-to-moment awareness, on purpose, in a particular way, without judgment’. Mindfulness practice has a wealth of supporting research in pain and oncology patients where the ability to recognize, acknowledge and release difficult thoughts, emotions, and physical sensations has been correlated with improved quality of life and decreased anxiety, depression and prescription pain medication use.
Mindfulness-based stress reduction has gained broad acceptance in the medical community, with nearly 80% of the 140 accredited medical schools or their associated university programs in the US incorporating some type of mindfulness intervention into clinical treatment, educational, and or research programs. (Buchholz)
A comprehensive systematic review and meta-analysis by West et al reviewed 115 randomized controlled trials involving 716 physicians, and 37 unique cohort studies including 2914 physicians showed that most commonly studied interventions have included mindfulness, stress management techniques, and small group discussions. (West 1)
Important characteristics of mindfulness
Important characteristics of mindfulness related to physician wellness include enhancement of the sense of self-efficacy and cultivation of an internal locus of control, both traits closely associated with personal resilience. Additional important benefits recorded in physicians are:
- Stress reduction
- Increase in self-awareness
- Improved listening and attentiveness
- Increase in attention, compassion, self-compassion
- More thoughtful decision making
- Increased adaptive reserve
- Reduction in rumination (West 2)
Emerging research on the impact of mindfulness on telomeres and telomerase, linked to longevity and improved health are another reason to consider mindfulness as a useful skill for physicians to acquire. (Fair)
Mindfulness to promote physician wellness can be applied in a wide range of settings, from an individual approach where the physician pauses and centers themselves prior to entering each patient room, to group settings where physicians can learn a range of mindfulness techniques applicable in practice settings ranging from the surgical suite, emergency department, or ICU to primary care or hospice.
The research findings, power, and flexibility of this highly teachable skill invite further exploration and may be of service to you throughout the span of your career. An excellent resource is the Center for Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Medical School, Worcester, MA. https://www.umassmed.edu/cfm/
Shanafelt, et al. Building a Program on Well-Being: Key Design Considerations to Meet the Unique Needs of Each Organization. Acad Med. 2018 Aug 21. PMID: 30134268
Buchholz, L. Exploring the Promise of Mindfulness as Medicine. JAMA. 2015 Oct 6;314(13):1327-9. PMID 26441167
West, et al.(1). Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Nov 5;388(10057):2272-2281. PMID: 27692469
West, et al. (2) Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial JAMA Intern Med. 2014 Apr;174(4):527-33. PMID: 24515493
Fair, et al. Telomere length is inversely correlated with urinary stress hormone levels in healthy controls but not in un-medicated depressed individuals-preliminary findings. J Psychosom Res. 2017 Aug;99:177-180. PMID: 28712425