physician wellness mindfulness in medicine aleksandra zgierska, md, phd primary care faculty...

Physician Wellness

Mindfulness in Medicine

Aleksandra Zgierska, MD, PhDAleksandra Zgierska, MD, PhD

Primary Care Faculty Development Primary Care Faculty Development

FellowshipFellowship

University of Wisconsin, School of Medicine and Public University of Wisconsin, School of Medicine and Public

Health, Department of Family MedicineHealth, Department of Family Medicine

Madison, WI, Nov 12, 2010Madison, WI, Nov 12, 2010

Department of Family Medicine

Physician Wellness

High quality of care delivered

Job satisfaction stability of workforce

Personal quality of life / family life

Life Balance

When wellness is compromised:

physician burnout Emotional exhaustion

Depersonalization (treating patients as objects)

Low sense of accomplishment

Increased stress

Consequences of Burnout

quality of life

quality of care

sense of accomplishment Life / work dissatisfaction Instability of workforce Divorce Depression – suicide Addiction

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 Today’s Tense, Frustrated Doctors,” K. Pho, D. Farrago, Medscape Business of Medicine, 10/26/09

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.

‘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.

Prevention / Treatment of Burnout

Lack of “standardized” treatment Lack of system-wide approaches

“Enhancing Meaning at Work:

a Prescription for Preventing Physician Burnout

and Promoting Patient-Centered Care.”

Shanafelt TD, JAMA, 2009, 302:1338.

Prevention / Treatment of Burnout

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/news-now/professional-issues/20091109mindful-comm.html

11-2009

What is Mindfulness Meditation ?

Originated in Originated in many ancient many ancient religions/culturreligions/cultures across the es across the worldworld

Mindfulness Meditation (MM)

MM

Meditation

Mind-Body

Complementary &Alternative Medicine

Popularity has Popularity has beenbeengrowinggrowing

As a therapy, itAs a therapy, itis already used is already used in clinical settingsin clinical settings

Meditation “meditation” = technique of an

intentional regulation of attention

focus on the present moment

autopilot

Mindfulness

the way we pay attention to the present moment: on purpose, non-judgmentally, with acceptance

with openness, curiosity, kindness

practiced by using meditation

““being in the present moment”being in the present moment”

better recognition of thought patterns,better recognition of thought patterns,

emotions, sensationsemotions, sensations

mindful response mindful response (vs. “autopilot”)(vs. “autopilot”)

helps act reflectively (non-judgmentally) rather than impulsively

Mindfulness Meditation

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

Personal Growth and Well-being:

Long-term Practitioners Buddhist monks Buddhist monks (R. Davidson’s studies)(R. Davidson’s studies)

gamma brainwave activity gamma brainwave activity

suggesting:suggesting:

intelligenceintelligence

compassioncompassion

self-controlself-control

happinesshappiness

Meta-analysis (10 studies) Meta-analysis (10 studies) evaluating effects of mindfulness evaluating effects of mindfulness training:training: stressstress

ruminative thinkingruminative thinking

empathyempathy

compassioncompassion

spirituallyspiritually

quality of lifequality of lifeChiesa A, J Altern Complement Med, 2009

Personal Growth and Well-being: Healthy Individuals

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

Health Care Providers

After Mindfulness training, After Mindfulness training,

nursing, pre-med & medical students:nursing, pre-med & medical students:

empathyempathy

stressstress

anxietyanxiety

Shapiro SL, J Behav Med 1998

Primary Care Physicians (N=70)

15 months after Mindfulness 15 months after Mindfulness training:training: burnoutburnout perceived stressperceived stress stress copingstress coping emotional stabilityemotional stability empathyempathy sustained well-beingsustained well-being attitude toward patient careattitude toward patient care

Krasner MS et al., JAMA 2009, 302: 1284-93

Health Care Providers:Better Treatment Outcomes

RCT of mental health RCT of mental health providersproviders Mindfulness training vs. Mindfulness training vs.

notnot

Trained providers had better mental health treatment outcomes in their patientsGrepmair L, Psychother Psychosom 2007

Mindfulness in Medicine benefits for providers AND patients

life-long effects & “transferable” skills

high client satisfaction

no side effects

non-stigmatizing

? cheap

Mindfulness: “… is a discipline and an attitude of mind” [its] “practice requires mentoring and

guidance.” … “can link evidence-based and relationship-

centered 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

Mindfulness in Medicine

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 providerHokusai, Big Wave

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

Vipassana meditation

the most ‘traditional’ approach

retreats (many - silent):

10-day Vipassana (www.dhamma.org)

varied duration: Insight Meditation(www.dharma.org)

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

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

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% !

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.”

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/aafpcours

es/conferences/assembly/cme/

plenaries0.html)

Other resources

UW DFM & MBSR website

Mindfulness in Medicine

http://www.fammed.wisc.edu/mindfulnesshttp://www.fammed.wisc.edu/mindfulness

UW MBSR

For Health Professionals

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. - “What’s called for NOW?” - use

mindful speech and action to respond compassionately, and with positive

intention.

Adapted from www.fammed.wisc.edu/mindfulness

Thank you !Thank you !

Aleksandra.Zgierska@fammed.wisc.eduAleksandra.Zgierska@fammed.wisc.edu