Using mindfulness to soothe physician stress

At a Rush University Medical Center continuing education course in Chicago last fall, a room of more than 80 physicians and other health professionals did something they rarely do during days packed with rushed patient encounters and consultations with colleagues — they sat together in silence for a solid 35 minutes.

In neat rows of chairs, the doctors, nurses, social workers, psychologists and other health professionals sat straight-backed with their hands on their knees and their eyes open, gazing into the middle distance. Throats were cleared, coughs pierced the stillness, and an elevated train rumbled just outside the conference room's picture windows.

“The effort in this practice is remembering to come back — back to your posture, back to your breathing, over and over again,” said Mitchell M. Levy, MD. He led the exercise, known as mindfulness meditation, with a quiet yet commanding tone of voice.

“Whatever thought or feeling arises, just bring it here,” he said. “Let it be here in this space.”

This sort of meditative exercise is only one element of what Dr. Levy and the course participants covered during two days in October 2012, and the well-attended course is just one sign of the rising interest among physicians, medical schools and hospitals in using mindfulness practices to help alleviate doctors' stress and reconnect them with their patients and their calling in medicine.

Nearly half of doctors report experiencing at least one symptom of burnout, according to a nationwide survey of 7,288 physicians, the results of which were published online Aug. 20, 2012, in Archives of Internal Medicine, now JAMA Internal Medicine. Symptoms of burnout include emotional exhaustion, depression, a low sense of professional accomplishment and depersonalization — a straining of physician empathy that translates into seeing patients as mere medical problems rather than individual people. Physicians are at greater risk of burnout than workers of the same age group in other professions, the study said.

At least a dozen U.S. medical schools offer formal training in mindfulness, and several programs around the country offer credit-eligible continuing education courses on mindfulness geared toward doctors and other health professionals. Mindfulness involves more than meditation, experts say. Other exercises involve practicing an awareness of one's body from moment to moment, yoga-style movements, bringing meditative awareness to a simple walk, and narrative exchanges with other physicians about meaningful medical experiences.

Leaders of the mindfulness-in-medicine movement argue that by learning to pay attention to each moment — how they are breathing, how they are feeling, and what their patients and colleagues are saying — physicians can improve their performance and ease the burnout that comes from excessive focus on factors outside their control.

Ready for a different approach

Dr. Levy has been practiced and taught mindfulness — practices that originated with the Buddhist tradition but spread to secular use in the U.S. — for more than 40 years. Yet he began formalizing instruction in mindfulness techniques for health professionals only recently. Dr. Levy led similarly well-attended courses in Providence, R.I., and Montreal that focus on using mindfulness to improve end-of-life care communication, and plans to offer the training later this year at Bellevue Hospital in New York and Tufts Medical Center in Boston.

“What I've discovered now, to my amazement, is how ready people are to embrace this,” says Dr. Levy, chief of the Division of Pulmonary and Critical Care Medicine at the Warren Alpert Medical School of Brown University and medical director of the Rhode Island Hospital medical intensive care unit in Providence. “It seems timely in the culture right now. People understand that there are so many forces that lead us to be distracted. We're being asked to do more in the caregiving setting than ever before, with fewer resources. … This is about how you take a distracted mind pulled in a million directions and give it a technique that allows it to rest and become clearer.”

Starting in September 2012, a condensed, four-hour version of the course was offered to Brown medical students and hospitalists, social workers, and medical nursing staff at Brown-affiliated hospitals. Internal medicine residents are required to take the course, Dr. Levy says.

Dr. Levy is a recent entrant to the growing movement to use mindfulness to help physicians. Michael J. Baime, MD, directs the Penn Program for Mindfulness at the University of Pennsylvania Health System in Philadelphia and has offered mindfulness training since the early 1990s. He estimates that more than 1,000 doctors and other health professionals have taken his training, which is an elective for Penn medical and nursing students. The eight-week course is limited to 40 students, most of whom are future physicians.

“It's always full, with a wait list,” Dr. Baime says, and that represents a shift from how his work used to be viewed. “Twenty years ago, what I did was totally off the beaten track, and I was a complete oddball for doing it. Now it's downright fashionable.”

A key goal of mindfulness training is to help physicians stay connected with their patients and practice deliberately on a moment-to-moment basis, Dr. Baime and other experts say.

“It helps people to undo some of the sense of the time pressure and urgency that makes it so hard to feel present for your patient, and it helps your patients feel like you're really there, really listening and that you really care,” Dr. Baime says. “What you learn is to undo the distractedness that comes with worrying about what happens next, and the concern with what's already over and done with. It doesn't take more time; it takes an intention and practice to do it successfully.”

Small moments make a mark

The time commitment involved in mindfulness training sometimes worried Sharon J. Glezen, MD, medical chief of the University Health Service at the University of Rochester Medical Center in New York. She took a mindfulness course for physicians that took place over the course of a year. The training began with weekly 2½-hour sessions and a seven-hour retreat during the first two months, and continued with once-a-month, 2½-hour sessions for an additional 10 months.

After a day trying to keep up with her busy patient schedule, Dr. Glezen says she would see the training appointment on her calendar and think, “Oh, golly — there's another two hours.”

Yet the training helped relieve her stress, she says. When she is at work and finds herself becoming anxious and feels her heart racing or her face becoming flushed, Dr. Glezen will take a moment before entering the next patient's room to take three deep breaths. Though she has not kept up her meditation regimen since completing the mindfulness training, Dr. Glezen says that even such small actions are a balm.

“Sometimes,” she says, “I'll turn off the radio on the way to and from work just to have a little bracket of silence on either part of my day, instead of listening to the sad news of our broken world. … And when I'm walking from the parking lot to my office, I try to take advantage of what nature has to offer around me, knowing I may not be outdoors for the rest of the day until it's dark. I try to be more aware of using my senses — noticing the color of the sky and the feel of the wind on my face.”

Impact on physicians examined

The course that Dr. Glezen took was part of a study on the efficacy of mindfulness training the results of which were published in the Sept. 23-30, 2009, issue of The Journal of the American Medical Association. She and 69 other primary care physicians were surveyed before, during and after the training course to see how it affected them. On average, the doctors reported feeling less emotional exhaustion, depersonalization, anger, depression and fatigue. They also saw higher levels of personal accomplishment, empathy and vigor, the study found.

In addition to training doctors how to meditate and pay attention to their bodily senses, participants in the Rochester course wrote and talked with their fellow physicians about experiences such as difficulties with patients, times when they felt split between caring for themselves and others, and when they found meaning in their work.

“Looking at all those stories, we find we're tremendously gifted to have such intimate experiences with patients and families in their lives,” says Michael S. Krasner, MD, lead author of the JAMA study and co-leader of the Rochester training. “But we have little time or training to safely and appropriately reflect on them in a way that would improve our capacity to continue to do the work, rather than taking on the suffering of our patients and having a secondary trauma. Instead, we can become invigorated by the work itself. I think that's what this kind of training does.”

The JAMA publication sparked interest from Physicians' Reciprocal Insurers. The Roslyn, N.Y., physician-owned medical liability insurer asked Dr. Krasner to help them create a three-hour mindfulness CME activity for doctors. The course was launched in spring 2011, and more than 8,000 physicians took it online or in person to qualify for a 5% premium discount on an added $1 million layer of coverage, company officials say.

Not everyone is impressed with the JAMA results. Because physician participation was self-selected and there was no control group exposed to a placebo intervention, the study is far from conclusive, says David H. Gorski, MD, PhD, a Detroit breast cancer surgeon who often writes critically of complementary and alternative medicine research at the blog Science-Based Medicine.

“The fact that this study was not a randomized trial, that there was no control and that there wasn't even an attempt at blinding renders it pretty much worthless,” Dr. Gorski says.

In response, Dr. Krasner says the view that anything worth doing in medicine must be tested with a randomized controlled trial is “too narrow and confining.” He adds that physician self-selection was part of the premise of the study, knowing it would draw interest from doctors who felt they needed to find ways to cope with the stresses of their lives in medicine.

“We were interested in determining what the effects of a program like ours would be on people who would actually take it,” Dr. Krasner says.

He estimates that 300 primary care physicians in the Rochester area have taken the mindfulness training. Starting in 2007, every third-year medical student at the University of Rochester School of Medicine and Dentistry was required to take the course, as were most medical residents. Dr. Krasner hopes to conduct further research to explore whether physicians trained in mindfulness achieve higher levels of patient satisfaction.

As fervent as their belief in the promise of mindfulness for the medical profession may be, Dr. Krasner and others say the technique does not eliminate stress.

Julie Goldstein, MD, section chief of clinical ethics and palliative medicine at Advocate Illinois Masonic Medical Center in Chicago, is one of the doctors who attended Dr. Levy's mindfulness course in October 2012. She has been doing some form of mindfulness meditation practice for more than a decade and has attended several training courses. Yet there are still times where her attention to the needs of patients and families wanders, and when the stresses of medical practice catch up with her.

“You know, we call it the practice of medicine and the practice of meditation,” she says. “It's about continuing and practicing, even when you don't get it right all the time.”