Mindfulness in Medicine: Promoting Physician and Patient Wellness ALEXIS M. STONER, PHD, MPH EDWARD VIA COLLEGE OF OSTEOPATHIC MEDICINE, CAROLINAS CAMPUS ASSISTANT PROFESSOR, DIRECTOR OF PREVENTIVE MEDICINE AND PUBLIC HEALTH Objectives 1. Define mindfulness as a process and an outcome 2. Identify ways in which mindfulness tools can contribute to greater well being in physicians. 3. Identify benefits of mindful awareness for physicians in improving patient outcomes 4. Identify benefits of mindful awareness and mindful practice for patients dealing with acute and chronic diseases. 5. Distinguish between basic evidence based mindfulness techniques. Questions for the Audience 1
Brief History Origins in ancient Eastern meditation practices Modern day mindfulness considered a secular practice inspired by 2,600 year old Buddhist teachings Historically practiced in isolated settings but now used in hospitals, clinics, schools, and businesses Jon Kabat Zinn founded 1 st mindfulness based treatment approach Mindfulness Based Stress Reduction (MBSR) What is Mindfulness? According to Jon Kabat Zinn, mindfulness means: paying attention in a particular way; on purpose, in the present moment, and nonjudgmentally. Also defined as the awareness that arises through intentionally attending in an open, caring, and nonjudgmental way In other words it is a heightened awareness; helps one be responsive rather than reactive; quiets all of our excess brain chatter The opposite of multi tasking! Important to distinguish mindfulness as both a process (mindful practice) AND outcome (mindful awareness) Why focus on the present? I have spent most of my life worrying about things that have never happened -Mark Twain 2
Mindful Awareness Knowing what you are experiencing as you are experiencing it Seeing clearly and accepting what is here and now Feelings Thoughts Perceptions Involves simply observing internal self without trying to get more of what one wants (pleasure, security), or pushing away what one doesn t want (e.g., fear, anger, shame) Mindful Awareness Patterns of behavior are conditioned and result in living on autopilot Awareness involves distinguishing between beneficial and unbeneficial tendencies People can develop insight from being aware of their internal experiences and ultimately make more deliberate choices Ability to sustain attention and switch focus of attention Crucial for effective rapport building with patients Accepting the Present Nonjudgmentally VS 3
Mindful Practice Way of intentionally pursuing mindful awareness Formal practice: systematic meditation practices that cultivate mindfulness skills (brief or intensive) Informal practice: application of mindfulness skills in everyday life; generalize what is learned in formal practice Let s Try it Together Mindfulness has to be experienced to be known. (Germer, Siegel, & Fulton, 2005, p.8) Mindfulness in Medicine Benefits for your Patients! Benefits for you! 4
Mindfulness as Medicine Recent studies show benefits for patients with acute and chronic diseases such as: Chronic pain, cancer, cardiovascular disorders, epilepsy, HIV/AIDS Meditation used successfully in treatment and prevention of high blood pressure, heart disease, migraine headaches, & autoimmune diseases (e.g. diabetes and arthritis) Proven helpful to curtail obsessive thinking, anxiety, depression, and hostility Mindfulness as Medicine Dr. Herbert Benson & colleagues at Harvard Medical School (1968) tested whether meditation could counter physiological effects of stress Found: Heartbeat and breathing rates slow down Oxygen consumption falls by 20% Blood lactate levels drop Skin resistance to electrical current increases fourfold EEG ratings indicate increased alpha activity Mindfulness Based clinical interventions Mindfulness based stress reduction (MBSR) 1st and most popular; intensive 8 week program includes formal and informal mindfulness practices & didactics Mindfulness based cognitive therapy (MBCT) 8 week program aimed at treating depression, particularly relapse prevention Similar to MBSR; varies in terms of mindfulness techniques 5
Mindfulness Based clinical interventions Acceptance and commitment therapy (ACT) Conducted individually; helps reduce avoidant coping styles Dialectical behavior therapy (DBT) Helps improve emotion regulation, distress tolerance, and ability to be mindful of others and their environment Mindfulness as Medicine Cancer patients who participated in an MBSR program showed improvements in mood (65%) and stress symptoms (35%)(Speca, Carlson, Goodey, & Angen, 2000) German research group found that women with Fibromyalgia showed improvements on measures of pain, coping, quality of life, anxiety, depression, and somatic complaints after completing MBSR (Grossman, Tiefenthaler Gilmer, Raysz, & Kesper, 2007) The Mindful Physician 6
Self Care for Physicians Self care is critical for health care professionals to have the strength and clarity to care for others Up to 60% of physicians and nearly 50% of 3 rd year medical students report symptoms of burnout* Burnout associated with poorer quality of care and lower quality of life Mindfulness may help with stress management, emotion regulation, energy level, empathy, and ability to be fully present for both good and bad daily life experiences Physician Burnout Patient overload Administrative pressure Work/life balance Exhaustion Lack of autonomy 2011 2014 Burnout 45.8% 54.4% Emotional Exhaustion 37.9% 46.9% Depersonalization 29.4% 34.6% Dissatisfied with work life balance 36.6 44.5% Changes in Burnout and Satisfaction With Work Life Balance in Physicians and the General US Working Population Between 2011 and 2014 Shanafelt, Tait D. et al. Mayo Clinic Proceedings, Volume 90, Issue 12, 1600 1613 Burnout and Quality of Care Physician burnout has been associated with: Higher levels of depersonalization resulting in lower patient satisfaction Longer post discharge recovery time Increase in medical errors Reduced standards for patient care Increased physician and medical staff turnover rates Workplace productivity and efficiency Physician depression, exhaustion, substance abuse and suicidal ideation 7
Self Care for Physicians Mindfulness increases self awareness and the ability to recognize how thoughts, feelings, perceptions may be impacting personal & professional relationships Dr. Michael Baime (among others) says A key goal of mindfulness training is to help physicians stay connected with their patients and practice deliberately on a moment to moment basis. How Some Physicians Benefit From Mindfulness Survey measure Baseline score 15 months later Decline Anger 6.6 3.0 55% Fatigue 8.4 4.6 45% Depression 9.1 5.4 41% Emotional exhaustion 26.8 20.0 25% Tension 15.1 12.4 18% 70 primary care physicians who took a year long mindfulness course reported lower stress and burnout symptoms The Impact of a Mindful Physician Improved patient centered care Decreased depersonalization Increased patient centered communication Increased patients and clinicians engaged in rapport building and discussion of psychosocial issues More positive emotional tone Increased patient satisfaction 8
Mindfulness techniques Formal Practice 1. Sitting Meditation (Breathing Awareness) 2. Mantra Meditation 3. Body Scan 4. Walking Meditation 5. Eating Meditation 6. Mindful Yoga Sitting Meditation (Basic mediation) Focus is on the breath Tune into sensations of breath entering nose or mouth, or rise and fall of abdomen Note sensory experiences as they arise hearing, reactions (e.g. enjoying a thought, urge to scratch an itch), then bring attention back to breathing Breath counting: count each exhale; note when mind wanders then simply start over & return to counting exhales Deep breathing: use of 4 senses Mantra Meditation Focus is on a word, syllable, or phrase of choice repeated over and over Make a list and read aloud to see what feels right or inspirational Common mantras: one, OM (pronounced aum traditional mantra), or calm Say mantra silently or aloud Be aware of each repetition and bring attention back if mind wanders 9
Body Scan Helps develop mind body connection Increases bodily sensations related to stress, pain, and other forms discomfort Usually practiced lying down with arms by sides, palms up, and legs hip width apart Focus attention SLOWLY and deliberately on each part of the body from head to toe or vice versa Notice sensations, emotions, thoughts, then let them go and return to exercise Walking meditation Focus is on the act of walking Mentally note lifting, stepping, placing as they happen naturally Pay attention to sensations in feet and lower legs Alternate way is to count steps with breathing ( in 2 3, out 2 3) Remember goal is not to get somewhere or exercise; it is to develop mindfulness Eating meditation Pay attention to each aspect of the eating experience Notice colors, shapes, smells as well as intentions and desire to begin eating Observe process of chewing and swallowing; silently label to help maintain focus or use non dominant hand Works best when eating alone 10
Mindful Yoga Practicing mindfulness skills while practicing yoga Notice feelings, areas of tension, judgments, comparisons with others, etc. and gently let them go Practice on own requires intention to be mindful while going through poses Helps calm the mind, cultivate kindness for the body and awareness of the body s capabilities Mindfulness Techniques Informal Practice Incorporating mindfulness as a way of life vs an isolated formal practice Practice mindfulness during everyday tasks that typically occur on autopilot mindlessly Grooming, eating, washing dishes, driving Mini meditation exercises can be practiced while waiting in lines, in traffic, or on hold Intentionally tuning in to body and breath throughout the day (ex. quick body scan while sitting in class) 5 3 1 Daily practice to reduce burnout Mediate for 5 minutes http://www.today.com/video/try an easy 5 minute meditation 478123587733 Identify 3 good things that happened Do 1 act of kindness 11
Easy Ways to Incorporate Mindfulness into Everyday Practice Choose one activity a day (brushing your teeth, taking a shower, getting the mail, etc.) Mindful movement stretching, walking Deep Breathing Recognize distraction and stress as it is happening and work to let it go quickly and easily! Practice between patients to clear your mind Spend time reflecting at the end of the day Common Mindfulness Misconceptions You need to be mindful 24 hrs, 7 days a week Mindfulness is a religious practice and conflicts with many religions Mindfulness is difficult Mindfulness is pushing away thoughts or emotions Mindfulness stops you from feeling emotions Your mind wanders too much for meditation Mindfulness takes a lot time Mindfulness is the same as relaxation Mindfulness benefits are always immediate When one door closes, another opens; but we often look so long and so regretfully upon the closed door that we do not see the one that has opened for us. Alexander Graham Bell The secret of health for both mind and body is not to mourn for the past, nor to worry about the future, but to live the present moment wisely and earnestly. Buddha 12
Questions? References Altman, D. (2011). One Minute Mindfulness: 50 Simple Ways to Find Peace, Clarity and New Possibilities in a Stressed Out World. Novato, CA: New World Library. Altman, D. Advanced Mindfulness Techniques That Change The Brain. Workshop (2014), Charlotte, NC. Black, D.S. (2011). A Brief Definition of Mindfulness. Mindfulness Research Guide. Accessed from http://mindfulexperience.org Davis, D.M. & Hayes, J.A. Monitor on Psychology. What are the benefits of mindfulness? July/August 2012, Vol 43, No. 7. Davis, M., Eshelman, E., McKay, M. (2000). The Relaxation and Stress Reduction Workbook. Oakland, CA: New Harbinger Publications, Inc. Grossman, P., Tiefenthaler Gilmer, U., Raysz, A., & Kesper, U. (2007). Mindfulness training as an intervention for fibromyalgia: Evidence of postintervention and 3 year follow up benefits and well being. Psychotherapy and Psychosomatics, 76, 226 233. Ives Deliperi, V. L. et al. (2011). The neural substrates of mindfulness: An fmri investigation. Social Neuroscience. Kabat Zinn, J. & Davidson, R. J. (2011). The Mind s Own Physician. Oakland, CA: New Harbinger Publications, Inc. References Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney, C.J., & Quill, T.E. (2009). Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. Journal of the American Medical Association. 302(12):1284 1293. O Reilly, K.B. (2013). Using mindfulness to soothe physician stress. American Medical News. http://www.amednews.com/article/20130107/profession/130109974/4/ Ospina, M.B., Bond, T.K., Karkhaneh, M.,Tjosvold, L., Vandermeer, B., Liang, Y., et.al. (2007). Meditation practices for health: State of the research (Evidence Report/Technology Assessment No. 155). Rockville, MD: Agency for Healthcar Research and Quality http://archive.ahrq.gov/clinic/tp/medittp.htm#report Shapiro, S. L., & Carlson, L. E. (2009). The Art and Science of Mindfulness: Integrating Mindfulness Into Psychology and the Helping Professions. Washington DC: American Psychological Association. Speca, M., Carlson. L.E., Goodey, E., Angen, M. (2000). A randomized, wait list controlled clinical trial: the effect of a mindfulness meditation based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613 622. 13