1. Beyond coping & preventing burnout, to caregiver well-being & growth Stephen Liben MD PEI June 2014

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4. Problems in clinicians… ___________ 4

5. The Problem Reaction 1.Avoiding suffering 2.Conflicts with patients and staff 3.Feeling overwhelmed, cognitive traps. 4.Unhappy professionals 5.Burnout, Unacknowledged Grief, Depression Outcome 1.Not listening 2.Lapses in professionalism 3.Bad Outcomes/Medical errors 4.Unhappy pts & parents. 5.Leaving practice… 5

6. 1.What is wrong with me? (Diagnosis) 2.What is going to happen to me? (Prognosis) 3.What can be done to help me? (Treatment) 4.Can you/will you, BE with me? Will you be there for me even when I feel things are hopeless? What do patients want when they seek medical care? 6

7. Questions that resonate How do we sustain & grow in the face of so much suffering that we see? What drains us? –Compassion fatigue… What energizes us in our work? 7

8. To Not Listen To Listen Mindfully Example of not listening – “Why did you have to keep asking me if I knew…?” A momentary pause – Listening with awareness to distress 8

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10. Challenged: Within & without We see others struggle & are affected –Can no more be in the presence of suffering and be unaffected than go swimming and not get wet. We React or Respond – –Compassion –Anger –Non-acceptance Can we move from being reactive to being responsive? 10

11. Challenged: Within & without Lost in reactive & unhelpful patterns- –Fixing instead of listening---coming to closure too soon (e.g. kleenex) –Not able to be there for the child and family in front of me = lack of presence (not being there) Reactivity – built in, conditioned, automatic Responsiveness – a skill we can learn 11

12. “Initial/Primary stability is what you feel when you first get into the boat. In a boat with great initial stability, you can stand up and walk around. It takes a lot of effort to flip this boat on flatwater. It resists leaning until it reaches a point of no return, beyond which it quickly upsets without much warning.” Primary Stability

13. “Secondary stability refers to how the boat behaves as it tilts. A boat with great secondary stability may feel tippy at first -it's easy to lean onto its side. But it feels stable and predictable in the lean. This is a useful characteristic for whitewater moves and rough-water paddling.” While primary instability is built in (reactive impulse) the capacity to develop secondary stability is a learnable skill… Secondary Stability

14. Do you turn the motorcycle steering wheel to the right or left if you want to go around a right sided-turn? 14

15. Between Stimulus & Response 15

16. Mindful awareness is not ethically neutral Mindfulness cares. “Caring attention to the present moment.” Intention to not to harm and by the proactive intention to be kind, compassionate, and generous. 16

17. Mindful awareness is simple, but not easy. Sometimes it’s easy, sometimes it’s not. Gets easier with practice, because you’re developing a habit. Mindfulness practice is like building a muscle in the brain: the mindfulness muscle. 17

18. Mindful awareness practice is not just meditation Mindful awareness exercises : Formal Practice –Body scan –Yoga –Mediation Informal Practice –Washing hands –Hand touching doorknob. In the moment - S.T.O.P. 18

19. Mindful awareness is not synonymous with joy The present moment is not always a pleasant moment. “Giving up” is not the same as “acceptance” (e.g. unwanted rain) 19

20. Mindful awareness is not passive. If you let go a little you will have a little peace; let go a lot you will have a lot of peace; let go completely… Caring attention also means that you know when to abandon observing your present moment experience & take action to prevent harm (e.g. abusive situations) 20

21. Mindful awareness is both the means and the end Mindfulness, in and of itself, is the goal. Wisdom is also the goal. 21

22. Mindful Practice 1.Willingness - Intention 22

23. Mindful Practice 1.Willingness - Intention 2.Know How – Awareness Practices –Formal & Informal methods 23

24. Mindful Practice 1.Willingness - Intention 2.Know How – Awareness practices 3.Effort towards building capacity “How do you get to Carnegie Hall?” 24

25. Objective To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. Design, Setting, and Participants Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians Michael S. Krasner, MD; Ronald M. Epstein, MD; Howard Beckman, MD; Anthony L. Suchman, MD, MA; Benjamin Chapman, PhD; Christopher J. Mooney, MA; Timothy E. Quill, MD JAMA. 2009;302(12):1284-1293. doi:10.1001/jama.2009.1384. 25

26. Main Outcome Measures: Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. Conclusions: Participation was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care.

27. Levels of Knowing 1.Not knowing (ignorance) 2.Knowing = knowledge 3.Realizing – grounded in lived experience 4.Actualizing – bringing the knowing into moment to moment awareness Example – Universality death 27

28. 28 Beyond coping…

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30. 3 questions to help dig for the reactive/unconscious subroutines Look at difference between intention and the result or outcome. = if there is a difference then reactivity is present. How to get curious about these reactive patterns? Ask these 3 questions ; –What do I not notice, –What do I not question, and –What am I not able to see some humor in… 30

31. Clinician Person Disease Healing Curing