1. MINDFULNESS IN MEDICAL EDUCATION Millaray Sanchez-Campos and Douglas Archibald Department of Family Medicine ADAPTED FOR the Annual DFM Retreat Montebello, QC September 20, 2014

2. Acknowledgments Carol Gonsalves MD, FRCP (C), MEd Diana Koszycki PhD Heather MacLean MD, FRCP(C) Veronique Duschesne MD Candidate Class 2016 Kay-Anne Haykal MD, CCFP

3. The following presentation is free from bias and the presenters are not affiliated with any for-profit organizations or parties. The presenters do not have any conflict of interests to disclose and are not affiliated with any commercial entities or organizations that serve to profit from this presentation. DISCLOSURE

4. Click View then Header and Footer to change this text FACULTY/PRESENTER DISCLOSURE Faculty: Dr. Sanchez-Campos and Dr. Archibald Relationships with commercial interests: None Disclosure of Commercial Support: N/A Mitigating Potential Bias: N/A

5. WORKSHOP OBJECTIVES To understand the scientific evidence about the importance of incorporating mindfulness in medical education (undergraduate, graduate and CPD) For clinical teachers in the DFM to learn about the UGME mindfulness curriculum at the University of Ottawa To provide an introduction to mindfulness practice and how it can help in building resilience

6. OUTLINE Introduction 15 minutes Practicing Mindfulness15 Minutes Mindfulness in Medical Education 10 minutes Discussion 10 minutes

7. OUR MODERN LIFE

8. PHYSICIAN HEALTH

9. BEING IN THE MOMENT...

10. What is Mindfulness Jon Kabat-Zinn Paying attention on purpose In the present moment Non- judgementally

12. WHAT IS MINDFULNESS " The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will... An education which should improve this faculty would be the education par excellence" William James, Principles Of Psychology, 1890

13. “NORMAL” DOING You have 45 minutes to get ready and o ff to clinic. While in the shower, you are already thinking about what you have to do as soon as you get into work… “Did I remember to check the results of the blood work that was done yesterday afternoon? Oh yes, I did. I’ll have to let the patient know the results as soon as I get in. And I have to meet with Jennifer about her rotation feedback. I hope she takes it well. What if she gives me a bad evaluation? I need to remember to leave the office on time to get the kids from school today. I can’t be late again. What should we for dinner tonight. We had spaghetti last night…and lunches…I forgot to pack lunches last night. Before you know it, your shower is over and you didn’t feel a drop of it.

15. “NORMAL” DOING You have 45 minutes to get ready and o ff to clinic. While in the shower, you are already thinking about what you have to do as soon as you get into work…

16. SCENARIO “DO- OVER”…MINDFULLY

17. “MINDFUL” DOING You are back in the shower. You’ve got the temperature just perfect. Just then your mind drifts to the list of things you need to do today. As soon as you realize this, you gently refocus your attention back to the here and now; The zinging sensation of the water jets hitting your skin. The warmth of the humid shower air filling your lungs with each deep breath. The surprising coldness of the tiles when you accidentally bump the shower walls. The gurgling sound of the water going down the drain sounding vaguely like music. Then a thought intrudes. -­ ‐ I’m worried about giving rotation feedback today. Like a loving parent redirecting a playful child, you gently reorient your thoughts back to your shower, the water, the steam. You hold the bar of soap up to your nose inhaling the fruity scent. The smell makes you happy and you notice you feel grateful for it -­ ‐ -­ ‐ it was a gift. You feel the soap slip and slide between your hands, noticing the stickiness of the soap slip and slide between suds between your fingers.

18. “MINDFUL” DOING You are back in the shower…

19. Medicine: The facts Physician Distress Burnout in 30-60% of specialists and GP More prevalent in private practice (55%-67%) than academic faculty (37%-47%) Medicine associated with burnout, depression, anxiety, substance abuse, divorce and broken relationships Shanafelt et al. The Well-Being of Physicians. The American Journal of Medicine. 2003;114:513-519

20. BURNOUT AND MEDICAL ERRORS Of the 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 Shanafelt et al; Burnout And Medical Errors Among American Surgeons. Ann. Sur 2009

21. BURNOUT AND SELF- REPORTED CARE 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

22. 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

23. MINDFULNESS PRACTICE ON STUDENT STRESS LEVEL 66 med. students in their clerkship at University of Tasmania Randomized to intervention, 30 min audio CD of guided mindfulness practice and a control group Self-report PSS (Perceived Stress Scale) and DASS (Depression, Anxiety and Stress Scale) at baseline and 8 wks. Warnecke et al. A Randomized controlled trial of the effects of mindfulness practice on medical student stress levels. Medical Education 2011:45:381-388

24. MBSR AND CHANGES IN GREY MATTER Memory process Emotion regulation Self-referential processing Perspective taking Holzel et al. Mindfulness Practice leads to increases in regional brain grey matter density. Psychiatry Res. 2011 January 30; 191 (1): 36-43

25. MINDFUL COMMUNICATION IN PCP 70 Primary care physicians enrolled in CME in Rochester, NY. 8-wk course, 2.5 hours/wk., a 7 h retreat, followed by a 2.5 h/mo x 10-month. Improvement in burnout, empathy, mindfulness, total mood disturbance and personality. Improvements in mindfulness were correlated with improvements in all other measures. Krasner, M, Epstein, R et al. Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians. JAMA, 2009; 302(12):1284-1293

26. SELF-MONITORING IN CLINICAL PRACTICE Self-monitoring as an important component of the professional competence of physicians It allows early recognition of cognitive biases Avoidance of technical errors Awareness of emotional reactions Facilitates self-correction Development of therapeutic relationships Epstein R. Mindful Practice in Action (II): Cultivating Habits of Mind. Fam Syst Health 2003:21:11-17

27. MINDFULNESS CURRICULUM

28. MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE 2012: A-pilot project of « Mindful Practice in Clinical Practice » was added as a teaching innovation to the 3rd year rotation in Family Medicine. PIME grant awarded to study this teaching innovation. Research is in progress. 2013-2014 class evaluations are very positive:

29. MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE definite eye opener truly enjoyed excellent Interesting insightful, relaxing, important to teach in the curriculum

30. MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE will try to make sure I use it in the future it prompted me to be present in my everyday life, will use in the future to relieve stress will definitely try to implement some of the mindfulness technique in my work and daily routine now I try to be mindful before doing things

31. MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE The session was well run and well led. This being said, it was time wasted. A mindfulness workshop is a great thing to offer to medical students outside of academic time. As a mandatory portion of our academic teaching, it is nothing short of a farce. Instead of choosing from a myriad of useful topics to teach from any area ranging from clinical medicine to pharmacology, I spent my academic morning eating a raisin and contemplating its texture. This is nonsense. In my opinion, this time should be spent on topics that will enrich our knowledge and performance as physicians

32. MINDFULNESS AT uOTTAWA FACULTY OF MEDICINE  Importance of incorporating a “Mindful Practice “ curriculum in medical schools  Sep 2014 will commence a 2-year- Mindfulness Curriculum for pre-clerkship at uOttawa  To be linked with workshop in mindfulness given in 3 rd year FM rotation with anticipated similar workshops in postgraduate programs in the future  Possibility to be linked with an online-MBSR program

33. OTHER FACULTIES OF MEDICINE  Canadian: McGill University, Montreal: Mindful Medical Practice (Drs. T. Hutchinson, Dobkin): Students; University of Toronto: Students/Residents; University of Alberta, Edmonton - Residents  Monash University (Australia):Health Enhancement Program (Dr. C. Hassed)  University of Rochester (NY): Mindfulness Curriculum for Clerkship (Drs. Krasner, Epstein)  University of Massachusetts (MA): The Contemplative Mind In Medicine (Drs. Santorelli and Kabat-Zinn)  Other electives throughout US, UK, Germany

34. STARTING A MINDFULNESS PRACTICE Stop-breath and be: Take few moments during the day to take 3-5 breaths, before starting a new activity and/or seeing a new patient 2-5 minutes of sitting meditation in am-hs Stop and breath at red/yellow lights Practice walking meditation Practice mindful listening

35. STARTING A MINDFULNESS PRACTICE Practice mindful eating/drinking for few minutes Use background noise to stop and take three breaths Breathe 3-5 times before getting up and at bedtime Being mindful when working out Bringing mindfulness to everyday activities

36. Guided meditation: www.mindfulselfcompassion.org Mindfulness meditation as a tool for compassion fatigue: https://compassionfatigue.ca RESOURCES

37. Modern Meditation Mindfulness Resources http://www.modernmeditation.ca/mindfulness- resources/

38. 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.

39. THANK YOU!