Summer Institute July 2014 University of Oklahoma School of Community Medicine

Jennifer K. Clark, MD

LOVE PLAY …that together they create one cohesive narrative. (E. Erickson) WORK Self We are most fulfilled when the basic outer expressions of ourselves— Work, Play, and Love—are developed in such a way….

 Your Why Self

but what does this have to do with Professionalism in Medicine??

 Shifting context of medical practice Artisan/Vocational to Humanistic Professional  The concept of professionalism as an expression of teachable behaviors rather than character trait or virtue. What then is the expectation of having basic core values to enter the profession?  Practice and teaching professionalism… The lynchpin of the hidden curriculum

4 CORE VALUES  Integrity  Respect  Compassion  Social Justice and Excellence in Care 2 DOMAINS  Individual interactions With patients/families With colleagues  Organizational behaviors Healthcare settings Advocacy and professional organizations Lesser et al., JAMA, 2010

“One way of defining the character of clinicians is to examine their moment-to-moment actions…These small actions, cumulatively, describe the clinician as a practitioner and moral agent” -Ron Epstein, MD Professionalism: it’s a relational thing

Community & Regulatory Organization Team Patient Professionalism: Behavioral skills developed from core values that are demonstrated in the interactions between professionals as well as between professionals and organizations. Crucial conversations and confrontations: the demonstrable acts professionalism: Self-Community & Regulatory Self-Organization Self-Team Self-Patient Self-Personhood Advocacy: the intersect of work, play, and love Self

Practicing Professionalism

ADAPTIVE CAPACITY  Self-awareness  Interpersonal skills  Intention of healing -Lesser et al -Epstein et al

Recognize it’s an everyday thing Self-reflect….explicitly Offer your narratives Practice mindfulness Expose the hidden curriculum Demonstrate intolerance to unprofessionalism

 As members of organizations, reflect on your current environments… Are you engendering a system where you or others are forced to be unprofessional?

Steve Hoppes, Ph.D.

“Mindfulness means moment-to- moment nonjudgmental awareness.” Jon Kabat-Zinn (2011, p. 231) “ Mindfulness is the energy that helps you be fully present with whatever is there.” Thich Nhat Hanh (2002, p. 51)

 Effective in reducing anxiety, depression, panic symptoms, mood disturbances, chronic pain, and stress. (Brown & Ryan, 2003; Kabat-Zinn et al., 1992; Minor et al., 2006; Teasdale, et al., 2000)  Reductions were maintained in 3-month & 3-year follow-ups. (Kabat-Zinn et al., 1992; Miller et al, 1995.)

 Mindfulness training resulted in improved immune function, even in patients with HIV. (Siegel, 2011)  Mindfulness training resulted in enhanced self- compassion. (Germer & Neff, 2013).  Mindfulness has been shown to be effective in treating conditions such as obsessive- compulsive disorder, borderline personality disorder, and drug addiction. (Witkiewitz & Bowen, 2010; Siegel, 2011)

 “ … meditation can produce increases in relative left-sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect.” (Davidson, et al., 2003) ch?v=gJ1_Bmx7QdY&featur e=related

 302 Jefferson Medical College students.  Over 10 weeks, students trained in mindfulness experienced decreased Total Mood Disturbances (TMD) (p=0.05), including  Decreased anxiety (p=0.009), confusion (p=0.009), and depression (p=0.09), while increasing vigor (p=0.006). Control group: Increased TMD (p<0.0001), anxiety (p<0.0001), confusion (p=0.02),, and depression (p = 0.06), while vigor (p<0.0001) decreased.

 In a study of 30 primary care physicians, brief mindfulness training was associated with reductions in indicators of job burnout, depression, anxiety, and stress (Fortney et al., 2013).

 Presence “Our true home is not in the past. Our true home is not in the future. Our true home is in the here and now.” Thich Nhat Hanh  Equanimity  Open-heartedness  Connectedness “We are here to awaken from our illusion of separateness.” Thich Nhat Hanh

 "I help people as a way to work on myself, and I work on myself to help people."

 Brown, K.W., & Ryan, R.M. (2003). The benefits of being present: Mindfulness and its role in psychological well- being. Journal of personality and social psychology, 84,  Hanh, T.N. (2002). Be free where you are. Berkeley, CA: Parallax Press.  Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M. A., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K., & Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65,  Fortney, L., et al. (2013). Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. Annals of Family Medicine, 11,  Germer, C. K., & Neff, K. D. (2013). Self ‐ compassion in clinical practice. Journal Of Clinical Psychology, 69(8),  Kabat-Zinn, J. (2005). Coming to our senses. NY: Hyperion.

 Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L., Lenderking, W.R., & Santorelli, S.F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–43.  Miller, J.J., Fletcher, K.E., and Kabat-Zinn, J. (1995). Three- year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17,192–200.  Rosenzweig, Reibel, Greeson, Brainard, & Hojat. (2003). Mindfulness based stress reduction lowers psychological distress in medical students. Teaching & Learning in Medicine, 15,

 Siegel, D. (2011). The proven benefits of mindfulness. In B. Boyce (Ed.), The Mindfulness Revolution, pp , Boston: Shambhala.  Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness based cognitive therapy. Journal of Consulting and Clinical Psychology, 68,  Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78,