Mindfulness and Medicine

Depression and anxiety are rampant in healthcare. A recent meta-analysis in JAMA demonstrated up to 30% of medical residents are clinically depressed (Mata et al., 2015). Residents are not alone. Although few will admit it, many medical faculty and staff also suffer from stress, anxiety and depression (McCue, 1982). These symptoms can lead to burnout, manifested as: physical and mental exhaustion, depersonalization, cynicism, and low sense of accomplishment (Krasner et al., 2009). Burnout increases the likelihood of substance abuse, stress-related medical problems, marital and family discord, and errors in patient care (Krasner et al., 2009).

Unfortunately, burnout / depression often begin early in training. In a study in 2009, almost 50% of medical students reported signs of burnout (Krasner et al., 2009). This is not surprising given the ever-changing, anxiety-provoking environment of modern medicine, greater regulatory oversight, the changes brought about by the information explosion, and the weighty responsibility of holding human lives in our hands.

Once, about a decade ago, I was working with a transplant surgeon who had been operating non-stop for a 48-hour period. Chatting him up as I often do in the OR, I commented that he must be exhausted. I cited literature I recently read on the performance of Army Rangers when sleep deprived (Ranger's cognitive and physical performance fell precipitously after 16 hours of sustained performance). The surgeon didn’t skip a beat — in extremely colorful language he looked me in the eye and told me he was 10 times tougher than a Ranger! Unfortunately, in medicine, there remains a stigma against admitting vulnerability or asking for help. Many physicians put on a tough face and labor on.

Some practitioners, like the surgeon mentioned above, wear their fatigue as a badge of honor. But many others don’t, and suffer in silence. Many doctors are too scared to speak up. So many of us endured physical and psychological pain during our training, suffering through sleep deprivation and mind-numbing stress with the overlay of patient suffering and the ever present specter of patient death. Over our career, I believe each patient we’re unable to adequately help / cure adds to our psychological toll.

Unfortunately, the stress does not end with training—it endures throughout a physician’s career. With stress a part of our daily lives, one would think we as a profession have developed ways to effectively intervene. Unfortunately, we have not. Few programs make self-care an ongoing part of physician training (Dobkin and Hutchinson, 2013).

I have noticed a lessening of bravado amongst medical practitioners over the past 10 years. I hope this trend continues. Despite the the more frequent acceptance of vulnerability, the issue of stress and suffering endures as this recent blog post, by an anonymous surgeon discusses. Unfortunately, many physicians continue to suffer in silence.

There is a minority of practitioners who feel trainees should be able to endure stress—after all, they did. To those old school practitioners, stress is a right of passage. I strongly disagree. Enduring stress flies in the face of each of the pillars of mental and physical health: sleep, exercise, diet, and stress-management. It’s time to break the cycle.

In modern medical centers, stress management resources are available for trainees, faculty, and staff, but continue to be underutilized. One evidence-based way to break the cycle of stress is using Mindfulness (Buchholz, 2015). Mindfulness is a secular technique based on Buddhist teachings that was popularized by by John Kabat-Zinn for patients with chronic illness.

I’ve been a fan of mindfulness and meditation for close to a decade. I truly wish I had started earlier. I’ve practiced meditation using timers and more recently with meditation-specific apps like Headspace and meditation equipment like the Muse Headband. I’ve found meditation helps me manage my stress and gives me greater focus both in my personal and professional lives. I believe we do a disservice to our learners by not making mindfulness a mandatory and frequent part of training.

For those of you that are still skeptical—there is an ever increasing pool of literature on the benefits of meditation. A large meta-analysis published in JAMA Internal Medicine showed that meditation and mindfulness “resulted in small to moderate reductions of multiple negative dimensions of psychological stress (Goyal et al., 2014).” A study published in Lancet earlier this year, reported that mindfulness-based cognitive therapy (MBCT) is equivalent to antidepressants in halting the reoccurrence of depression (Kuyken et al., 2015) in patients. The two groups – one on medication, one treated with MBCT – had an essentially equivalent relapse rate of depressive illness. In practitioners, a study published in JAMA showed that physicians who participated mindfulness CME program demonstrated improvements in measures of well-being and patient centered orientation to clinical care (Krasner et al., 2009).

Although techniques such as Mindfulness have become more popular both with business and medical practitioners, many in healthcare are resistant to use integrative medicine, no matter the evidence supporting its benefit.

Stress management is one of the pillars of physical and mental health. I believe it’s time for self-management and stress reduction techniques to have a greater role in medicine. First, we have to de-stigmatize the perception of stress, anxiety, and depression in healthcare workers. Additional studies in undergraduate populations (Campisi et al., 2012) demonstrate that stress, regardless of level, is a ubiquitous problem in our learners. Because stress is ubiquitous in our learners, training to manage these emotions should begin early. In medical school, I believe stress management, mindfulness, meditation and other topics in physical and mental health should be introduced alongside anatomy and physiology in the very first weeks of medical school. These topics need to be revisited and reinforced at every transition of a trainee’s career (classroom to clerkship to internship to residency / fellowship, and finally practicing physician).

Only in this way will the use of mindfulness and meditation become ingrained in the fabric of medical care-and alleviate the suffering of countless practitioners and while allowing us to take better care of our patients—and ourselves.

Want more? Take a look at my recent lecture on Mindfulness...

REFERENCES
Buchholz L. Exploring the Promise of Mindfulness as Medicine. JAMA. American Medical Association; 2015 Oct 6;:1327–9.

Campisi J, Bravo Y, Cole J, Gobeil K. Acute psychosocial stress differentially influences salivary endocrine and immune measures in undergraduate students. Physiology & Behavior. 2012 Oct 10;107(3):317–21.

Dobkin PL, Hutchinson TA. Teaching mindfulness in medical school: where are we now and where are we going? Med Educ. 2013 Jul 10;47(8):768–79.

Goyal M, Singh S, Sibinga EMS, Gould NF, Rowland-Seymour A, Sharma R, et al. Meditation Programs for Psychological Stress and Well-being. JAMA Intern Med. American Medical Association; 2014 Mar 1;174(3):357–12.

Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009 Sep 23;302(12):1284–93.

Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 2015 Jul 4;386(9988):63–73.

Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians. JAMA. American Medical Association; 2015 Dec 8;314(22):2373–11.

McCue JD. The effects of stress on physicians and their medical practice. New England Journal of Medicine. 1982 Feb 25;306(8):458–63.

OTHER REFERENCES

W. Kuyken et al., Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet. 386, 63–73 (2015).

P. L. Dobkin, T. A. Hutchinson, Teaching mindfulness in medical school: where are we now and where are we going? Med Educ. 47, 768–779 (2013).

M. D. Mrazek, M. S. Franklin, D. T. Phillips, B. Baird, J. W. Schooler, Mindfulness Training Improves Working Memory Capacity and GRE Performance While Reducing Mind Wandering. Psychological Science. 24, 776–781 (2013).

J. A. Irving, P. L. Dobkin, J. Park, Cultivating mindfulness in health care professionals: A review of empirical studies of mindfulness-based stress reduction (MBSR). Complementary Therapies in Clinical Practice. 15, 61–66 (2009).

J. Carmody, R. A. Baer, Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction …. Journal of Behavioral Medicine. 31, 11–33 (2008).

L. N. Dyrbye et al., A multicenter study of burnout, depression, and quality of life in minority and nonminority US medical students. Mayo Clinic Proceedings. 81, 1435–1442 (2006).

S. L. Shapiro, J. A. Astin, S. R. Bishop, M. Cordova, Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial. International Journal of Stress Management. 12, 164–176 (2005).

P. Grossman, L. Niemann, S. Schmidt, H. Walach, Mindfulness-based stress reduction and health benefits. Journal of Psychosomatic Research. 57, 35–43 (2004).

S. Rosenzweig, D. K. Reibel, J. M. Greeson, G. C. Brainard, M. Hojat, Mindfulness-Based Stress Reduction Lowers Psychological Distress In Medical Students. Teaching and Learning in Medicine. 15, 88–92 (2003).

K. W. Brown, R. M. Ryan, The benefits of being present: Mindfulness and its role in psychological well-being. J Pers Soc Psychol. 84, 822–848 (2003).

S. L. Shapiro, G. E. Schwartz, G. Bonner, Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine. 21, 581–599 (1998).