1. Translating the evidence about mind- body medicine into practice: Barriers and issues in training Victor S. Sierpina, M.D. W.D. and Laura Nell Nicholson Family Professor of Integrative Medicine Professor, Family Medicine University of Texas Medical Branch

2. Co-Investigators Ruth Levine, MD Professor of Psychiatry University of Texas Medical Branch John Astin, PhD Senior Scientist California Pacific Medical Center San Francisco, CA Alai Tan, MD, PhD Assistant Professor Office of Biostatistics Department of Preventive Medicine and Community Health University of Texas Medical Branch

19. Developmental Project 4 Barriers to Translation of Mind-Body Therapies to Training and Practice in Family Medicine and Psychiatry Victor S. Sierpina, M.D., Ruth Levine, M.D. John Astin, Ph.D. This project will identify barriers to evidence-based, mind-body medicine being regularly taught in training or implemented into practice

20. Developmental Project 4—Aims To survey residents and faculty at UTMB in family medicine and psychiatry programs comparing specialty responses. Introduce mind-body skills groups and training into both family medicine and psychiatry residencies. Perform a subsequent national survey of family medicine and psychiatry residency program directors and chief residents

21. Working hypotheses A number of specific factors can be identified that block the integration of MBM into patient care. Personal exposure to MBM techniques and experiences will improve the acceptance of these methods among clinicians.

22. Barriers To Translation Model Informed by qualitative, quantitative studies and literature review Survey designed around identified items from focus groups* *{Astin JA, Goddard T, Forys K. Barriers to the integration of mind- body medicine: Perceptions of physicians, residents and medical students. EXPLORE: The Journal of Science and Healing. 2005}

23. From Research to Health Outcomes: Translation Blocks to Mind-Body Medicine CLINICAL RESEARCH CONTINUUM Basic Science Research Translation from Basic Science to Human Studies Attitudes to Use/Validity of MBM Translation Block Personal psychological factors, need for control Education, Culture, and Belief System Personal transformational experiences Peer support, medical culture Practice environment, time demands Patient expectation Self efficacy, expectation of positive outcome Variables

24. Clinical Science and Knowledge Translation of New Knowledge Into Clinical Practice and Health Decision Making Clinical Trials of MBM Peer support, medical culture Practice environment, time demands Patient expectation Self efficacy, expectation of positive outcome Attitudes to Use/Validity of MBM Clinical Practice of MBM Referral to MBM Practitioners Variables Improved Health

25. Previous findings—Astin’s National Survey 1/3 of physicians acknowledged importance of psychosocial issues but doubted addressing them would make much difference in health outcomes A minority believed they had effective training in these areas or desired more {Astin, et al. J Am Bd Fam Prac in press, 2006}

26. Barriers Poor training Lack of self-efficacy/control Lack of knowledge of evidence base Inadequate time/reimbursement {Astin, et al. J Am Bd Fam Prac in press, 2006}

27. Mind Body Medicine methods explored in current survey Biofeedback Guided imagery Hypnosis Meditation Relaxation therapies Yoga and Tai Chi Not specifically inquired about: Cognitive behavioral therapy Psychoeducational approaches

33. Summary of findings There was little difference between physicians’ responses in the two specialties Substantial reports that barriers to the use of MBM were largely based on lack of training, inadequate expertise, and insufficient clinic time Lack of expertise and insufficient clinic time were higher among family physicians than psychiatrists There was a high interest in both groups in learning relaxation techniques and meditation and lower interest in biofeedback and hypnosis

34. Summary of Findings Female physicians significantly more likely to utilize MBM in both their own self-care and with patients Female physicians less likely to be concerned that recommending these therapies would make patients feel that their symptoms were being discounted Female physicians also had significantly higher beliefs about the benefits of MBM on health disorders than males in several of the conditions examined, with a consistent, though non-significant trend in others.

35. MBM/Stress Management Curriculum SNAPSHOT VIEW

37. A mental focusing device A passive attitude to distracting thoughts Deep, relaxed, abdominal breathing { Benson H, Stuart E. The Wellness Book, 1992} The Relaxation Response

38. 1. Focus word 2. Sit quietly in comfortable position 3. Close your eyes 4. Relax muscles 5. Breath slowly, naturally, repeat focus word 6. Assume passive attitude 7. Continue 10-20 minutes 8. Daily practice 9. When distracting thoughts occur, return to focus word, breathing Steps to eliciting the Relaxation Response

40. Stress Survival Strategies for Health Care Professionals and Patients Victor S. Sierpina, MD Nicholson Professor of Integrative Medicine Department of Family Medicine UTMB

42. Some intrinsic stressors in Medicine  Staffing  Scheduling  Time pressures  Diagnostic challenges  Malpractice  Sleep deprivation and shift work  PTSD  Role ambiguity among residents  Depressed immunity

43. Patient related stressors  Communication issues with patients and their families, verbal abuse  Violence  Exposure to infection: hepatitis, AIDS, SARS, MRSA, DRE, other “bug du jour”  Drug seekers  Social, financial problems of patients

44. What Can Be Done About Stress?  Biological interventions  Psychological interventions  Social interventions

47. Personal/social stress resilience approaches  Music listening and music making  Self reflection  Spiritual well-being, prayer, religious practice  Massage  Essential oils  Cognitive behavioral strategies  Biofeedback  Humor  Mindfulness based stress reduction  Psychodrama  Imagery  Relaxation therapies

48. Some Simple Techniques  Deep breathing  Progressive Muscle relaxation  Music  Meditation

53. Future studies National survey of FM and Psych Residency Directors and Chief Residents (IRB review of revised on-line survey in progress) Evaluation of impact of MBM training on FM and Psych residents personal and professional practices (proof of concept to follow pilot) Focus on how MBM training can help programs attain competencies in Professionalism

54. Manuscripts produced Sierpina V, Levine R, Astin J, Tan A. Use of Mind-Body Therapies in Psychiatry and Family Medicine Faculty and Residents: Attitudes, Barriers, and Gender Differences. Explore: The Journal of Science and Healing {under review—2006}

55. Manuscripts produced Sierpina V, Astin J, Giordano J. Behavioral and Mind-Body Therapies for Migraine and Tension Headaches. Am Fam Phys {under review—2006} Astin JA, Soeken K, Sierpina VS, Clarridge BR. Barriers to the integration of psychosocial factors in medicine: Results of a national survey of physicians. J Am Bd Fam Pract. {in press-2006}

56. Reference manuscripts Astin JA, Goddard T, Forys K. Barriers to the integration of mind-body medicine: Perceptions of physicians, residents and medical students. EXPLORE: The Journal of Science and Healing. 2005;1 (4):278-283. Astin J. Mind-body medicine: State of the science, implications for practice. J Am Bd Fam Pract. 2003;16:131-147

57. Acknowledgement Supported by grants from the National Institutes of Health: Mind-Body Exploratory and Development Grant #1 R21 AG023951-01 from National Institute of Aging and Office of Biobehavioral and Social Science Research (VSS) #R01 AT00869-04 from the National Center for Complementary and Alternative Medicine (JA) CAM Education Grant #1 R25 AT00586-01 from National Center for Complementary and Alternative Medicine (VSS)