MINDFULNESS and REFLECTIVE NARRATIVE Workshop for 3rd Yr. Medical Students Department of Family Medicine Millaray Sanchez-Campos MD, CCFP, FCFP Lynn Bloom, MSW RSW Contributors: Dr. C. Gonsalves and Dr. H. MacLean Acknowledgements: Donna Williams Watch link to begin presentation: http://www.youtube.com/watch?v=hnOPu0_Ywhw

https://www.youtube.com/watch?v=hnOPu0_YWhw https://www.youtube.com/watch?v=hnOPu0_YWhw

WORKSHOP OBJECTIVES Learning self-awareness Improving communication   Learning self-awareness Improving communication Learning how to build resilience “To cure sometimes, To relieve often, To comfort always” Hippocrates “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your mind” Sir William Osler

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your mind” Sir William Osler “To cure sometimes, To relieve often, To comfort always” Hippocrates

MEDICINE, THE FACTS Physician Distress Burnout in 47% of specialists and GP Medicine associated with burnout, depression, anxiety, substance abuse, divorce and broken relationships 1. Shanafelt et al. Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172 (18):1377-1385 2. Shanafelt et al. The Well-Being of Physicians. The American Journal of Medicine. 2003;114:513-519

PHYSICIAN SUICIDE Of all the occupations, physicians nearly at the top of all occupations with the highest risk of death. The results of depression and other mental illness. Physicians are reluctant to ask for help and to take into their own advice. Same rate or higher than average population, 12% for males, 19.5% for females. Higher in students and residents 15-30% Same in female and males.

BURNOUT AND MEDICAL ERRORS Of 7905 American College Surgeons, 700 (8.9%) reported concern they had made a major error in last three months Over 70% attributed error to individual factors Error reporting had statistically significant adverse relationship with mental quality of life Burnout and depression were independent predictors of reporting a recent major medical error Shanafelt et al; Burnout and Medical Errors among American Surgeons. Ann. Sur 2009;XXX:000-000

BURNOUT AND SELF-REPORTED CARE IN AN INTERNAL MEDICINE RESIDENCY PROGRAM Of 115 (76%) responding residents, 87 (76%) met the criteria for burnout (Maslach burnout inv.) Burnout residents were significantly more likely to self report suboptimal patient care at least monthly (53% vs. 21%; p=0.004). Shanafelt et al. Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program. Ann Inter Med. 2002; 136:358-367 Burnout: Depersonalization, cinicism, lack of professional accomplishment

Physician Wellness/Burnout Shanafelt et al. 2009; Wallace JE, LemaireJB, Ghali WA. Physician Wellness. Lancet 2009; Physician Burnout, 2014 CMAJ

EMPATHY IN MEDICAL SCHOOL Medical students from a university-based medical school surveyed yearly from 2007 through 2010, using Jefferson Scale of Physician Empathy-Student Version (JSPE-S) Empathy scores of students in pre-clinical years were higher than in clinical years Gender was a significant predictor of empathy, women > men Chen et al. Characterizing changes in student empathy throughout medical school. Med Teach. 2012;34(4):305-11

Reflective Writing Is good for our health (Pennebaker et al.) Helps us contain and share experience, rather than flooding us (Frank, 2010) Illuminates 4 of medicine’s “central narrative situations”: physician and patient, physician and self, physician and colleague, physicians and society (Charon, 2001) As part of a Mindfulness program, it improves physician wellness and enhance the physician-patient relationship by focusing on personal reflection, expression and communication, through story (Krasner, 2009) Deepens perspective both for the writer, and for those who listen and respond to the work (Devlin et al, 2014).

Mindfulness Definition Jon Kabat-Zinn Paying Attention On Purpose In the Present Moment Without Judgement

“...A human mind is a wandering mind, and a wandering mind is an unhappy mind. The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost.” Killingsworth MA, Gilbert DT. A wandering mind is an unhappy mind. Science. 2010:330

Brain Default System

Default System: Busy, Wandering Mind

CREATIVE AND ORIGINAL THINKING THINK BETTER, THINK LESS Less obsessive rumination Less preoccupations or “mental load” Baror and Bar; Associative Activation and its Relation with Activation and Exploitation in the Brain; Psychological Science, Feb 2016

MINDFULNESS PRACTICE

“May you Live Everyday of your Life” Jonathan Swift

The HUMAN stress response curve Modified from Nixon, practitioner 1979

RESILIENCE An ability to recover from or adjust easily to misfortune or change (Webster Dictionary) Capacity to learn from difficulties and mistakes Self confidence, capacity to get help Perseverance albeit difficulties Self control

“A connection made or not made”

Now take 5 minutes to reflect with a partner on what you just learn What are your comments and impressions? Any resolutions for the future? If so, what

MINDFULNESS AND REFLECTIVE NARRATIVE CONCLUSIONS

Mindfulness Physician Quality of care well-being (safety –errors) (resilience – burnout) Mindfulness The objectives of these sessions are to: Understand the concept of mindful practice and how it is related to quality of care and physician well-being Demonstrate how to cultivate mindfulness during everyday practice Quality of caring (empathy - detachment) ©Mindful Practice Programs, University of Rochester, 2010 24

Greater Satisfaction with Work/Life Improved Performance Reduced Stress More Empathy Greater Satisfaction with Work/Life

Mindfulness Practice Reflective Narrative

Starting a mindfulness practice Stop, breath and be: take few moments during the day to take 3-5 breaths Before starting a new activity Before seeing patients Red/yellow lights Before getting up and at bedtime Meditation 2-5 minutes of sitting meditation in morning or evening Walking meditation RESOURCES https://itunes.apple.com/ca/book/mindfulness-for-medical-school/id914285826?mt=11 www.calm.com www.mindfulselfcompassion.org http://www.modernmeditation.ca/mindfulness-resources/ smiling mind https://headspace

Resources https://itunes.apple.com/ca/book/mindfulness-for-medical-school/id914285826?mt=11 www.calm.com www.mindfulselfcompassion.org http://www.modernmeditation.ca/mindfulness-resources/ smiling mind https://headspace

Resources Kabat-Zinn, Jon. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion, 1994. Kabat-Zinn, Jon. Full Catastrophe Living. Bantam Dell. New York. 1991 Tolle, Eckhart. The Power of Now. Novato, CA: New World Library, 1999 Hanh, Thich Nhat. You Are Here. Boston: Shambhala Publications, 2001

Reflective Writing Resources Charon,R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press,2006. Frank, A. Why doctor’s stories matter. Canadian Family Physician 2010; 56:51-57. Peterkin A. Using reflective writing with students: ten tips. CAME Newsletter , Special Editions: May, 2010.

Submission of your Creative Writing (remember confidentiality - either written permission or patients should not be recognizable) Crawford, A. et al. Eds. Ars Medica: A Journal of Medicine, The Arts and Humanities. To contribute, check the following website: http://ars-medica.ca/index.php/journal/login Canadian Medical Association Journal : 750-1400 words under “Humanities Encounters” http://www.cmaj.ca/site/authors/preparing.xhtml#humanitiesEncounters

Submission of your Creative Writing (Cont’) Dzwonek, A. et al. (2016) Murmurs: The Journal of Art and Healing, v.III. University of Ottawa, Faculty of Medicine. Available at https://murmursmag.files.wordpress.com/2016/04/murmurs-edition-3.pdf To contribute contact: murmurseditors@gmail.com OMA Medical Student Publication. Scrub In. https://www.oma.org/MEDICALSTUDENTS/Pages/ScrubIn.aspx

Thank you! msanchez@uottawa.ca CITATIONS: Kabat-Zinn, Jon. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York: Hyperion, 1994. Kabat-Zinn, Jon. Full Catastrophe Living. Bantam Dell. New York. 1991. Tolle, Eckhart. The Power of Now. Novato, CA: New World Library, 1999. Hanh, Thich Nhat. You Are Here. Boston: Shambhala Publications, 2001. msanchez@uottawa.ca