physician wellness mindfulness in medicine aleksandra zgierska, md, phd primary care faculty...
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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 !
[email protected]@fammed.wisc.edu