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Mindful Practice: Bringing Mindfulness to Clinical Practice

for Our Patients and for Ourselves Hospital Authority

Hong Kong January 20, 2014

Mick Krasner MD, FACP

Professor of Clinical Medicine

University of Rochester School of Medicine and Dentistry

The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated.

Plato (427-347 BCE)

A Physician= Emotion + Passion + Science

RH Brook. JAMA 2010, 304: 2528

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Ars longa, vita brevis, occasion praeceps, experimentum periculosum, iudicium difficile.

Art is long, life is short, opportunity fleeting, experiment dangerous, judgment difficult. Hippocrates of Kos (460-370 BCE)

The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient…

...One of the essential qualities of the clinician is interest in humanity,

for the secret of the care of the patient is in caring for the patient.

FW Peabody. JAMA 1927; 88:877-882

f

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Even in this era of healthcare as a business, with increasing pressures to contain costs,

the secret of being a good doctor clearly still lies in what we do, feel, and communicate at the bedside. …redouble our efforts to

truly care for patients

H Bazari. NEJM 2010; 363: 2187-2189

You only get one chance. You have one journey through life; you cannot repeat even one moment or retrace one footstep. It seems that we are meant to inhabit and live everything that comes toward us.

John O’Donohue (1956-2008)

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Intention

Attention

Attitude

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Questions

What is the mission of medicine?

Nature of suffering and the goals of medicine

Experienced by persons

Source: threats to biopsychosocial intactness

Twin Obligations: relief of suffering, cure of disease

Failure of the physician to understand this may lead

to more suffering

EJ Cassell. NEJM 1982; 306: 639-45

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Questions

What is the mission of medicine?

What is the nature of health professional suffering?

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More than any other time in history, mankind faces a crossroads. One leads to despair and utter hopelessness. The other, to total extinction.

Let us pray that we have the wisdom to choose correctly.

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Woody Allen

WANTED: 21st Century Physician

(Health Professional)

Altruistic, compassionate, courageous, intellectually

curious, frugal scholar, gifted in history, philosophy,

politics, economics, sociology, and psychology.

Must have working knowledge of biology, chemistry,

physics, and medicine.

F Fitzgerald. Annals of Internal Medicine 1996

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WANTED: 21st Century Physician

Physical endurance, emotional maturity, and technical-

manual skills sufficient to take apart and reassemble

the human body and mind at levels ranging from the

micro-molecular to the gross are required; must have

flexibility to master all knowledge, sift and discard

that no longer applicable, while discovering new data

at the bench, in clinical practice, in both general and

subspecialty medicine.

Teaching, counseling, administrative, computer, and

budgetary expertise essential, as is commitment to the

disenfranchised.

WANTED: 21st Century Physician

A working knowledge of the law; literary, artistic, and

musical talent; and multilingualism highly desirable.

Should be able to prevent and cure disease, including

the depredations of advancing age; physical disarray;

and spiritual, mental, emotional, and economic

illnesses.

Will need to function effectively and efficiently in

both intensive care units and urban slums.

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WANTED: 21st Century Physician

Salary ideally should be no issue, though heavy initial

investment by the candidate is required.

Benefits variable, depending on the individual's

principal source of gratification.

This is a 24 hour per day commitment.

WANTED: 21st Century Physician

Should make house calls

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Health Professional wellness

Threatened by increased patient-care demands,

bureaucracy, conflict between needs of the organization and patients, compassion fatigue, suffering, pain, death, emotionally charged situations, diminished autonomy…and suboptimal attention to self-wellness

Results in increased turnover, reduced “productivity,” diminished quality of care, decreased patient safety…and diminished patient satisfaction and adherence to treatment

Wallace et al. The Lancet 2009; 374: 1714-21

Burnout appears early in training , with an uncertain prognosis

25% - 60% of practicing physicians

76% of internal medicine residents

45% - 53% of 3rd year students

Remission rate = ~ 50% at 12 months

Dyrbye LN et al. 2006 and 2010; Shana felt TD et al. 2003

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Why clinician distress matters

Lower quality of technical care Riskier prescribing practices More medication errors Lower patient adherence to treatment More unsafe behaviors (e.g. needlestick injuries, not following protocols)

Lower patient satisfaction Erosion of altruism and empathy Unprofessional conduct Poor relationships with staff and patients Higher attrition and job turnover higher recruitment costs

Fahrenkopf et al. 2008; DiMatteo et al. 1991; Williams et al. 2009; Shanafelt et al. 2005; Dyrbye et al. 2010; Haas et al 2000; Sundquist et al 2000; Krasner et al. 2009; Buchbinder et al. 2001

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Clinician resilience

(well-being – burnout)

Quality of care (safety –

errors)

Quality of caring (compassion - detachment)

Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program.

Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personal

well-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.

A word about burnout

Three components:

•Emotional exhaustion – I just can’t do any more

•Depersonalization (cynicism) – Every good deed gets punished

•Low personal accomplishment – No matter how hard I work, nothing improves

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Burnout

Erosion of the soul (Maslach)

Deterioration of values, dignity, spirit and will (Spickard)

Silent anguish of healers (Neuwirth)

Culture of endurance (Shanafelt)

Failure of adaptive reserve (Beckman)

Proposing a continuum

BURNOUT

• Withdrawn

• Emotionally exhausted

• Going through the motions

• Worn down, brittle

• Cynical, hopeless

• Hypercritical

• Brittle

• Feeling ineffective

• Becoming more rigid

• Treading water

RESILIENCE

• Engaged

• Energized

• Sticking to a mission

• Bending but not breaking

• Capacity for positivity

• A light touch

• Flexible, bouncing back

• Becoming stronger

• Adapting to stress

• Moving forward

• “AFGO”

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Balance

Career fit Overwork

Work / home

Work Environment

Unsupportive Competitive

Productivity pressures Too many demands

Not enough time Too much change Low control / high

responsibility

Psychological factors Alienation Moral distress Affect regulation Mental stability Self-awareness Self-monitoring

Physical Sleep Pain Illness

Freeborn 2001; Nedrow A et al 2013; Shanafelt TD et al. 2003, 2009, 2012

What causes burnout?

Values

Positive values

Service, altruism

Excellence

Curative competence

Knowledge

Empathy

Caring

Equanimity

After Nedrow, A et al 2013

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The dark side Positive values

The dark side

Service, altruism

Over-commitment, self-deprivation, entitlement

Excellence Perfectionism, invincibility, hiding errors

Curative competence

Omnipotence, imposter syndrome, self-deprecation

Knowledge Need for certainty

Empathy Personal distress

Caring Neglecting oneself and family

Equanimity Distancing, “othering”

Resilience Positive values The dark side Resilience

Service, altruism

Over-commitment, self-deprivation, entitlement

Reframing, balance, gratitude

Excellence Perfectionism, invincibility, hiding errors

Self-compassion, reflective self-questioning

Curative competence

Omnipotence, imposter syndrome, self-deprecation

Knowing one’s limitations

Knowledge Need for certainty Knowing what’s unknown, comfort with uncertainty

Empathy Personal distress Compassionate action

Caring Neglecting oneself and family

Self-care

Equanimity Distancing, “othering” Engagement

After Nedrow, A et al 2013

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Why are some people more resilient than others under extreme stress?

• Developmental / psychological

– Stress inoculation – the ‘right’ dose of stress

– Secure attachment style (not avoidant/fearful)

– Capacity for mentalization and affect regulation

– Learned self-efficacy (vs learned helplessness)

– Practice of self-compassion and self-regard

…and

Why are some people more resilient than others under extreme stress?

• Neuro/endocrine

– HPA axis, DHEA, testosterone, neuropeptide Y, serotonin, dopamine, BDNF (neurotropic factor)

• Socially-mediated epigenetic expression

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CAREER FIT

… the extent to which an individual is able to focus their effort on the aspect of work that they find most meaningful

Shanafelt Arch Int Med 2009

20%

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Questions

What is the mission of medicine?

What is the nature of health professional suffering?

What do the roots of 21st century medicine tell us about the current frontier

Asklepion Healing

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Asklepion Healing

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Ambrosia of Athens became blind in one eye. She

had laughed at being told of cures to the lame

and the blind. But she dreamed that Asclepius was standing beside her, saying he would cure her if she would dedicate a silver pig as a memorial to her ignorance. He seemed to cut into her diseased eyeball and pour in medicine. When she woke in the morning she was cured.

Aristagora of Troezen had a worm in her belly, so she slept in the sanctuary of Asklepios in Troezen. And she had a dream, in which it seemed to her that the sons of the god, while he was still in Epidauros, came and cut off her head by mistake. But they couldn't put it back again. So they sent someone to the Asklepieion in Epidaurus so that Asclepios would return. Meanwhile the day overtook them and the priest clearly saw the head removed from the body. When night finally came again, Aristagora had a new vision. It seemed to her that Asclepios had returned from Epidauros and put the head back on her neck. And after that he cut open her belly, took out the worm and sewed it up again. And from this she became well.

• `

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Hippocratic Oath

late 5th century BCE

Hippocrates or one of his students

Statement of professionalism

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents… I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect… Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

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Questions What is the mission of medicine?

What is the nature of health professional suffering?

What do the roots of 21st century medicine tell us about the current frontier?

What is the relationship between mindfulness and relationship-centered care?

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You can observe a lot by just watching Yogi Berra

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Mindfulness

• Integral to professional competence • A quality of consciousness • Attends to the context in which the contents of

consciousness are expressed • Can be cultivated, grown, expanded

• Attentive observation, critical curiosity,

beginner’s mind, presence

Why should mindfulness matter to clinicians?

• Quality of care

• Empathy

• Avoids cognitive traps and resulting errors

• Clearer assessments

• Promotes a more participatory medicine

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Mindful Communication

Bringing Intention, Attention, and

Reflection to Clinical Practice

The greatest problem in communication is the illusion that it has been accomplished.

George Bernard Shaw (1856-1950)

The limits of my language mean the limits of my world…You cannot enter any world for which you do not have the language.

Ludwig Wittgenstain (1889-1951)

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Clinical Vignette

• T

The mistaken case of the nursemaid’s elbow

Krasner in Best Buddhist Writing of 2007

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Mindless Communication?

•

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Mindful Practice

The ultimate value of life depends upon awareness and the power of contemplation rather than mere survival

Aristotle (384-322 BCE)

Mindful Practice • Enhancing intra-

personal and inter-personal self-awareness can improve well-being and effectiveness in clinical practice.

• More attentive to the presence of stress

• More aware of one’s relationship with the sources of stress

• More attentive to practitioner’s capacity to attenuate stress

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Clinician well-being (resilience vs.

burnout)

Quality of care ( patient-centeredness

fewer errors)

Quality of caring ( empathy,

compassion,

responsiveness)

Mindful practice

Narrative Medicine

The curious case of the man whose wife thinks he’s depressed

Krasner in Best Buddhist Writing of 2007

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Narrative Medicine Narrative Competence: set of skills required to recognize,

absorb, interpret and be moved by the stories one hears. It requires:

textual skills -identifying a story’s structure, adopting its multiple perspectives, recognizing metaphors and allusions

creative skills -imagining many interpretations, building curiosity, inventing multiple endings

affective skills -tolerating uncertainty as a story unfolds, entering the story’s mood

R Charon. NEJM 2004; 350: 862-4

Appreciative Inquiry

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Appreciative Inquiry

The art of asking questions that strengthen a system’s capacity to apprehend, anticipate, and heighten positive potential

David Cooperider

Appreciate

• Recognizing the best in people, programs, and the world around us

• Affirming past and present strengths, successes and potentials

• Perceiving those things that give life, health, vitality to living systems

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Inquiry

• The act of exploration and discovery

• Quest for the unknown

• Asking questions; Being open to seeing new potentials and possibilities

Achieving Coherence

Meaningfulness: Life makes sense. Thus coping and adjustment are desirable

Manageability: One senses that one has resources required to meet demands and a willingness to search them out

Comprehensibility: The world is perceived as understandable, meaningful, orderly and consistent, rather than chaotic, random and unpredictable

Antonovsky A. Health, Stress and Coping, 1979

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Human Motivation

Autonomy: Is the universal urge to be

causal agents of one's own life and act in harmony with one's integrated self, and not meant to be independent of others

Competence: Refers to being effective in

dealing with the environment in which a person finds oneself

Relatedness: Is the universal want to

interact, be connected to, and experience caring for others

Deci E and Ryan R. Handbook of Self-Determination Research , 2002.

Mindful Communication

Mindful

practice

Narrative

Appreciative

inquiry

Greater

self-awareness

Lower reactivity

Contextualize to

particular

encounters and

communication

challenges

Building on

strengths to

find new

solutions

Increased

attentiveness,

responsiveness

and presence

More

effective

communication

with patients

Improved physician

self-efficacy, vitality

satisfaction, and

confidence

Reduced physician

stress and burnout

Improved

patient

satisfaction

Improved practice

efficiency

Figure 1: A model of mindful practice, narrative and appreciative inquiry

and their effects on communication, physician well-being and clinical outcomes

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Appreciative inquiry interviews

Focus on a difficult moment in which you were at your best…

Describe the event in detail, including personal attributes and contextual factors

Reflect on how those attributes will be applied in future situations

Themes

Pleasant / unpleasant experiences

Perceptual biases

Meaningful experiences

Surprises

Burnout

Attraction

Dismissing patients

Self-care

End-of-life care

Conflict

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JAMA 2009; 302: 1284-93

Participants

70 Primary care physicians

54% Male, 46% Female

49% Internists, 41% FP, 10% Peds

71% suburban , 25% urban

15.9 years in practice

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Results: Mindfulness and Burnout Burnout:

Emotional Exhaustion 0.62 p<.001

Depersonalization 0.45 p<.001

Personal Accomplishment 0.44 p<.001

Mindfulness:

Total 1.12 p<.001

Observe 1.03 p<.001

Nonreact 0.88 p<.001

Results: Mood and Personality

Profile of Mood States:

– Total Mood Disturbance 0.69 p<.001

– Depression 0.55 p<.001

– Anger 0.76 p<.001

– Fatigue 0.81 p<.001

• Personality Minimarkers:

– Conscientiousness 0.29 p<.001

– Emotional Stability 0.45 p<.001

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Results: Empathy and Physician Belief

Jefferson Scale of Physician Empathy:

– Total Empathy 0.45 p<.001

– Standing in the patient’s shoes 0.36 p=.003

– Perspective taking 0.38 p=.001

Physician Belief Scale: 0.37 p=.001

Results: Correlations with Mindfulness

• Burnout: – Emotional Exhaustion r -.32 p<.001

– Personal Accomplishment r .33 p<.001

• Mood Disturbance: – Total Mood Disturbance r -.39 p<.001

– Tension r -.31 p<.001

– Depression r -.34 p<.001

– Fatigue r -.32 p<.001

• Personality: – Conscientiousness r .29 p<.001

– Emotional Stability r .25 p<.001

• Empathy – Perspective taking r .31 p<.001

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Participant narratives

Professional isolation and the desire to share challenging clinical experiences (building

community)

Development of skills to increase personal awareness and professional presence (becoming more present)

Balancing needs for personal development and self care with the demands of home, family and work (guilt and permission)

Beckman, et al. Academic Medicine, 2012; 87(6): 1-5

Building community

“Simply gathering [physicians]… together into a meeting place where they were invited to reflect more deeply…. Just that is tremendous, and that it happened over a year’s time, I think, was very significant…. It takes time for those stories to unfold. That seemed to me, a real engine for both developing community and fostering introspection.”

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Becoming more present

“I will spend extra time with my patients if they need it, but I felt in some ways that it was kind of sucking me dry… It’s not that I don’t empathize with them anymore, but [now] I feel OK just to listen and be present with them… and I think that in some ways that helps them more…”

Becoming more honest

“One of the things that comes out of this is that when you establish a practice of thinking more honestly, thinking more clearly, speaking more honestly, that definitely leaks out into your work every day. It certainly opens you up to being more ready with patients, colleagues, and family, to have … a more intimate, more honest interaction with people…. That certainly was the case for me that came out in the rest of my work. It certainly made it much more immediate and easy to do in [my] practice.”

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Well being and quality of care

“Originally I was doing it for the stress reduction, and then as time went on…. I’m learning how to communicate … with myself as much as anybody else…. I sort of gave myself permission to start thinking.”

Guilt and permission

“I felt this guilt about being there and not being at home, and my wife didn’t even make me feel guilty. It was just me.”

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Optimism More and more I have come to admire resilience. Not the simple resistance of a pillow, whose foam returns over and over to the same shape, but the sinuous tenacity of a tree: finding the light newly blocked on one side, it turns in another. A blind intelligence, true. But out of such persistence arose turtles, rivers, mitochondria, figs -- all this resinous, unretractable earth.

~ Jane Hirshfield ~

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• Spend a few minutes thinking about a clinical or personal experience in which you felt the healing power of relationship.

– Perhaps it was an experience with someone very close to you, involving your own healing.

– Perhaps it was something you did or some way you were for the sake of another.

– Perhaps it was something delightful, or perhaps it was something more ominous.

• Turn toward someone sitting near you, introduce yourself, and share your narrative

• For the storyteller: address what happened, what helpful qualities

you brought to that moment, what lessons from this story are useful to you

• For the listener: be attentive, don’t interrupt, don’t talk about

your own ideas or experiences, ask questions that help you partner clarify and add details, use reflective questions and empathy when appropriate

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Hippocratic Oath-Modern Version I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk… I will apply, for the benefit of the sick, all measures that are required… I will remember that there is art to medicine as well as science Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

In caring for the sick, I will strive to:

-listen with my heart as well as my mind

-always place the patient at the center…

-create a space that is welcoming and open…

-break down those barriers, internal and external, that separate me from the suffering and joy experienced by those around me

-act with mindfulness and lovingkindness

-provide extraordinary care and sustenance to those who have neither the means nor the will to seek help…

Rheumatololgist

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I promise to always put the patient at the center of my practice. I will treat the human being and try to consider the world in which he lives…I will try to stay aware of my own feelings, beliefs and biases as I treat my patients…I will remember that I am only one link in a long chain of caregivers…I will try to remember that neglecting my own health and well being may negatively affect my patients. Really caring about myself and my patients should be at the center of what I try to do.

Medical Student

May I know the simple grace of witness- the healing salve of patient listening. I vow to slow down enough for tender honesty and to speed up enough for joy. I hope that patients will find in me a compassion for their suffering, a keen mind for ways to relieve it, and a dedication to share my knowledge in language they can understand. May I remember …-that my patients are loved by others who suffer in their love. This is to be respected and tenderly acknowledged-while being ever mindful that in the end the patient is at the center…

Neurologist

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Oath:

Do the right thing.

Medical Student

e Attempts to understand all the known

dimensions of personhood and their relation to illness and suffering presents problems of staggering complexity. The problems are no greater, however, than those initially, posed by the question of how the body works-a question that we have managed to answer in extraordinary detail. If the ends of medicine are to be directed toward the relief of human suffering, the need is clear.

EJ Cassell, NEJM 1982

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Acknowledgments

Nancy Adams

Howard Beckman MD

Ben Chapman PhD

Ron Epstein MD

Mary Jane Milano

David Monsour MD

Jan Moynihan, PhD

Chris Mooney

Tim Quill MD

Tony Suchman MD

Melissa Wendland

Physicians Foundation for Health Systems Excellence

NY Chapter, American College of Physicians

Monroe County Medical Society

University of Rochester Center for Mind-Body Research

Rochester Individual Practice Association

A Society of Souls: School of Nondual Healing

The Rochester Zen Center

The Center for Mindfulness, University of Massachusetts School of Medicine