1. Physician Wellness Mindfulness in Medicine Aleksandra Zgierska, MD, PhD Primary Care Faculty Development Fellowship University of Wisconsin, School of Medicine and Public Health, Department of Family Medicine Madison, WI, Nov 12, 2010

2. Department of Family Medicine

3. Physician Wellness High quality of care delivered Job satisfaction  stability of workforce Personal quality of life / family life Life Balance

4. When wellness is compromised: physician burnout Emotional exhaustion Depersonalization (treating patients as objects) Low sense of accomplishment Increased stress

5. Consequences of Burnout  quality of life  quality of care  sense of accomplishment Life / work dissatisfaction Instability of workforce Divorce Depression – suicide Addiction

6. Primary care “An alarming number of physicians, unable to cope with the pressures of practicing everyday medicine, succumb to the stress. Consider that 300-400 doctors in the U.S. kill themselves every year, or roughly 1 per day. Male doctors have suicide rates 1.4 times that of a general population, while female doctors have twice the rate of depression and 2.3 times the suicide rate when compared with women who are not physicians.” “Help for Today’s Tense, Frustrated Doctors,” K. Pho, D. Farrago, Medscape Business of Medicine, 10/26/09

7. Primary care Surveys of PCPs: up to 60% of practicing physicians report symptoms of burnout, in part due to worsening time pressures and a chaotic work pace, which were strongly associated with low physician satisfaction Maslow Burnout Inventory Linzer et al, Ann Intern Med, 2009, 151: 28-36; Spickard et al, JAMA 2002, 288: 1447-50; Shanafelt et al: Am J Med, 2003, 114: 513-19.

8. ‘Pathophysiology’ of Burnout Burnout may be related to lack of sense of control and loss of meaning Dunn et al, J Gen Intern Med, 2007, 22: 1544-52 Study of physicians found that the capacity of “being present” with their patients correlated more strongly with finding meaning in their work than diagnostic or therapeutic successes. Horowitz et al, Ann Int Med, 1995, 138: 772-76.

9. Prevention / Treatment of Burnout Lack of “standardized” treatment Lack of system-wide approaches

12. “Enhancing Meaning at Work: a Prescription for Preventing Physician Burnout and Promoting Patient- Centered Care.” Shanafelt TD, JAMA, 2009, 302:1338. Prevention / Treatment of Burnout

13. New initiatives…. One possible approach to address loss of meaning and feeling of lack of control is through developing greater mindfulness “AAFP News Now: 'Mindful Communication' Can Help Physicians Deal With Burnout, Says Study.” www.aafp.org/online/en/home/publications/news/news- now/professional-issues/20091109mindful-comm.html 11-2009

14. What is Mindfulness Meditation ? Originated in many ancient religions/cultures across the world Originated in many ancient religions/cultures across the world

16. Mindfulness Meditation (MM) MM Meditation Mind-Body Complementary & Alternative Medicine Popularity has been Popularity has beengrowing As a therapy, it As a therapy, it is already used in clinical settings

17. Meditation “meditation” = technique of an intentional regulation of attention  focus on the present moment  autopilot

18. Mindfulness the way we pay attention to the present moment: on purpose, non-judgmentally, with acceptance with openness, curiosity, kindness practiced by using meditation

19. “being in the present moment” “being in the present moment” better recognition of thought patterns, better recognition of thought patterns, emotions, sensations  mindful response (vs. “autopilot”) helps act reflectively (non-judgmentally) rather than impulsively Mindfulness Meditation

20. Mindfulness Meditation therapy mental health problems stress, anxiety, depression, ADHD, borderline personality disorder, sleep problems, bulimia addictive disorders cardiovascular disorders other chronic conditions: obesity, psoriasis, diabetes, cancer, AIDS

21. Personal Growth and Well-being: Long-term Practitioners Buddhist monks (R. Davidson’s studies) Buddhist monks (R. Davidson’s studies)  gamma brainwave activity suggesting:  gamma brainwave activity suggesting:  intelligence  intelligence  compassion  compassion  self-control  self-control  happiness  happiness

22. Meta-analysis (10 studies) evaluating effects of mindfulness training: Meta-analysis (10 studies) evaluating effects of mindfulness training:  stress  stress  ruminative thinking  ruminative thinking  empathy  empathy  compassion  compassion  spiritually  spiritually  quality of life  quality of life Chiesa A, J Altern Complement Med, 2009 Personal Growth and Well-being: Healthy Individuals

23. Personal Growth and Well-being After Mindfulness training:  antibody titer after flu shot  positive emotions brain imaging studies: biological changes (  prefrontal cortex,  amygdala activity) Improved stress biomarkers cortisol, cytokines

24. Health Care Providers After Mindfulness training, After Mindfulness training, nursing, pre-med & medical students:  empathy  empathy  stress  stress  anxiety  anxiety Shapiro SL, J Behav Med 1998

25. Primary Care Physicians (N=70) 15 months after Mindfulness training: 15 months after Mindfulness training:  burnout  burnout  perceived stress  perceived stress  stress coping  stress coping  emotional stability  emotional stability  empathy  empathy  sustained well-being  sustained well-being  attitude toward patient care  attitude toward patient care Krasner MS et al., JAMA 2009, 302: 1284-93

26. Health Care Providers: Better Treatment Outcomes RCT of mental health providers RCT of mental health providers Mindfulness training vs. not Mindfulness training vs. not Trained providers had better mental health treatment outcomes in their patients Grepmair L, Psychother Psychosom 2007

27. Mindfulness in Medicine benefits for providers AND patients life-long effects & “transferable” skills high client satisfaction no side effects non-stigmatizing ? cheap

28. Mindfulness: “… is a discipline and an attitude of mind” [its] “practice requires mentoring and guidance.” … “can link evidence-based and relationship- centered care and help to overcome the limitations of both approaches.” … “should be considered a characteristic of good clinical practice” Epstein RM: “Mindful Practice”, JAMA 1999 Mindfulness in Medicine

29. Why Mindfulness …? Personal & professional journey Secular or religious – flexible “Better life” equanimity, happiness stress management life-long skills not a “therapy” “Better services” as a provider Hokusai, Big Wave

30. MM-based therapies Vipassana meditation Mindfulness Based Stress Reduction, MBSR Mindfulness Based Cognitive Therapy, MBCT Mindfulness Based Relapse Prevention, MBRP Dialectical Behavior Therapy, DBT Acceptance Commitment Therapy, ACT Spiritual Self Schema, 3-S

31. Vipassana meditation the most ‘traditional’ approach retreats (many - silent): 10-day Vipassana (www.dhamma.org)www.dhamma.org varied duration: Insight Meditation (www.dharma.org)www.dharma.org

32. Mindfulness Based Stress Reduction, MBSR UMass (Center for Mindfulness in Medicine, Health Care, and Society) Mindful Leadership Program Retreat: Cultivating Leadership Presence through Mindfulness (good !!!) next year: in WI by invitation / application

33. MBSR UW-Madison Integrative Medicine Dave Rakel, MD Research on preventing / treating burnout Meditation study for PCPs meditation course is free (PCPs are paid !) and abbreviated, with weekend / evening* schedule brochures available waiting lists for both

34. Mindfulness Based Cognitive Therapy, MBCT Designed for relapse prevention in depression http://www.mbct.com book: “The Mindful Way Through Depression” Strong evidence for depression, anxiety Andrew Moore, MD, WISPIC (UW Psych) courses designed for depression or anxiety most insurers cover them 100% !

35. Mindful Eating The Center for Mindful Eating (TCME) http://www.tcme.org “4 Easy Ways to Prevent Mindless Eating: Simple tips you can use to stop the unconscious munching. No ‘diet’ required.”

36. Other resources Lee Lipsenthal, MD Book: "Finding Balance in a Medical Life". AAFP video: “Living and Dying with Balance.” (www.aafp.org/online/en/home/cme/aafpcourses/ conferences/assembly/cme/plenaries0.html)www.aafp.org/online/en/home/cme/aafpcourses/ conferences/assembly/cme/plenaries0.html

37. Other resources UW DFM & MBSR website http://www.fammed.wisc.edu/mindfulness Mindfulness in Medicine http://www.fammed.wisc.edu/mindfulness http://www.fammed.wisc.edu/mindfulness UW MBSR  For Health Professionals

39. Mindfulness in daily life Pause Presence Proceed - stop, take a breath, ‘drop in’ - be aware of what is happening now: body sensations, thoughts, emotions; open to what is here; observe (accept) what arises for you just as it is, moment by moment, without reactivity. Listen deeply. - “What’s called for NOW?” - use mindful speech and action to respond compassionately, and with positive intention. Adapted from www.fammed.wisc.edu/mindfulness

40. Thank you ! Aleksandra.Zgierska@fammed.wisc.edu