Mindful Practice Curriculum for Psychiatry Residents: Experience as Part of a University Wide

ProgramTana A. Grady-Weliky MD, Sue K. DiGiovanni, MD, Scott McDonald, MD,

Jennifer Richman, MD, Anola Tanga, MD, David Garrison, MD, Christopher Mooney, MS and Ronald M. Epstein, MDUniversity of Rochester Medical Center

Department of Psychiatry

1. Connelly JE: Narrative Possibilities: Using Mindfulness in Clinical Practice. Perspectives in Biology and Medicine. 48(1): 84-94, 2005.

2. Dobie S: Reflections on a Well-Traveled Path: Self-Awareness, Mindful Practice and Relationship Centered Care as Foundations for Medical Education. Academic Medicine 82: 422-427, 2007.

3. Hassed C, deLisle S, Sullivan G and Ciaran P: Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv in Health Sci Educ. DOI 10.1007/s10459-008-9125-3, 2008.

Discussion Bibliography

Mindful practice refers to our ability to be aware, in the moment, on purpose, with the goal of providing better care to patients and to take better care of ourselves. The University of Rochester School of Medicine and Dentistry developed a program designed to give medical students, residents and practicing physicians’ tools that will assist them in becoming more mindful during daily clinical practice. The explicit aim of the curriculum is to help participants develop self-awareness and self-care skills so that they can be attentive and present in clinical settings. Self-awareness is an essential component of communication, technical skill, professionalism, teamwork and life-long learning. All of these attributes are included among the ACGME core competencies and are critical to training all residents, and perhaps, psychiatrists, in particular. Because of the importance of the development of these attributes in resident physicians, the general psychiatry program elected to have its residents participate in the university-wide program. General psychiatry residents from across the four years are required to attend the Mindful Practice curriculum sessions, which include the following sessions: 1) Noticing and Attention; 2) Professionalism; 3) How Doctor’s Think; 4) Physician Self Care and Burnout; and 5) Dealing with Medical Errors. Several educational methods are used throughout the curriculum including brief meditation exercises, written narratives and “appreciative inquiry” interviews. This poster will describe further details of the curriculum and include qualitative and quantitative data about the course.

Abstract Curriculum Goals and Objectives

Mindful Practice curriculum goals are to foster skills of attentive observation, critical curiosity, informed flexibility and presence in trainees at multiple levels.

Specific curricular objectives include: •To further professional development

Improve recognition of error-prone situations, reduce medical errors and improve reporting;

Foster caring attitudes toward patients; Promote professionalism, and prevent,

recognize and deal with lapses in professionalism; Promote physician health and well-being.

•To enhance the institutional culture to facilitate the aforementioned training goals through

More open discussion of medical errors; Focus on teamwork and leadership;

Modeling of effective patient care; Working on means to enhance physician health and well-being.

•To help residency programs meet ACGME competencies

Communication - through more attentive listening to patients;

Professionalism - through examining biases and threats to professionalism;

Systems-based practice - by examining and intervening to reduce individual contributions to medical errors;

Practice-based learning and Improvement - through greater openness and flexibility and a decreased tendency to premature closure.

Introduction

Narrative Exercise Instructions

2007-2009 Curriculum Modules

Educational Objectives

1. Define mindful practice and its role in the clinical care of patients.

2. List at least two components of mindfulness.

3. Identify at least two new educational methods for teaching mindful practice to psychiatric residents.

Goals of Mindful Practice

Mindful Practice•Attentive observation•Critical curiosity•Informed flexibility•Presence

•Clinical reasoning•Patient safety•Compassion•Technical skills•Healing relationships•Teamwork•Physician well-being

Reflective Questions: Habits of Self-Questioning

Attentive ObservationoIf there were data that you ignored, what might they be?oWhat did you notice? What were you unable to see?

Critical CuriosityoWhat are you assuming that might not be true?oWhat was surprising or unexpected?

Beginner’s MindoWhat would a trusted peer say about how you managed or feelabout this situation?oCan you see the same situation or patient with new eyes?

PresenceoWhat do you notice about yourself when you are at your best?oWhat moved you most about this situation?

For the storyteller, address:•What happened?•What helpful qualities did you bring to that moment? •Who else was involved, and how did they contribute? •What aspects of the context made a difference? •What lessons from this story are useful to you?

For the listener:•Be attentive•Listen without interrupting or responding too quickly •Ask questions to help your partner elaborate, clarify and provide details•Don’t talk about your own ideas or experiences•Use reflective questions •Pay attention to what is attracting your attention, and what you might not (or rather not) be hearing•Offer empathy if you feel it

2007-2008oNoticing and AttentionoProfessionalismoHow Doctor’s ThinkoPhysician Self-Care and Burnout*oDealing with Medical Errors** Well-received by psychiatry residents

2008-2009oTeams and PartnershipsoTimeoBalanceoManaging Conflict

Patient-centered and biopsychosocial models of care are essential elements of medical education. The important roles of relationship-centered care and a humanistic approach to care were highlighted in the Health Professions Education IOM report (2001) and the AAMC Ad Hoc Committee Report on Medical Education (2004). Recently, there has been more focus on the role of the ‘narrative’ in medical and residency education. The concept of narrative medicine includes the essential nature of closely examining each patient’s story in order to provide better medical care. Connelly addresses how the concepts of self-reflection and mindfulness are critical factors in being able to fully hear the patient’s story and to help relieve their suffering.1 Training students and residents to become more self-aware and to engage in mindful practice may not only improve patient care, but also reduce career dissatisfaction/burnout and facilitate wellness.2 In fact, Hassed and colleagues found improved physical and psychological well-being among medical students who participated in a mindfulness-based stress reduction program.3 The Mindful Practice Curriculum at the University of Rochester was initiated in 2007 with the primary goal of fostering skills of attentive observation, critical curiosity, informed flexibility, and presence in trainees at all levels.

Educational TechniquesAppreciative Inquiry – focus attention on existing capacities and prior successes in relationship building and problem solving.Personal Narratives – sharing of “real-life” or clinical stories based on the topic being addressed in the curriculumReflective Questions – help cultivate curiosity and new ways of seeing the world and may enhance one’s ability to listen and observe

Curriculum Assessment & Resident FeedbackIn the 2007-2008 academic year residents completed several surveys,

including the Maslasch Burnout Inventory (MBI), prior to and following participation in this curriculum. No statistical differences were found in the group (n=16) for any of the pre- and post- survey instruments. This is not too surprising given the small number of resident participants. Moreover, statistical differences in the survey instruments may not be found after a relatively brief intervention.

Unfortunately, a general anonymous course evaluation was not obtained for the 2007-2008 year. However, individual and group verbal feedback described a sense of redundancy of the narrative exercises with what is accomplished in psychotherapy supervision. They also noted that psychiatry residents are frequently talking about positive and negative interactions with patients, which made some of the sessions less beneficial. Only two of five sessions were highly regarded by the residents – Physician Self-Care and Burnout and Dealing with Medical Errors.Based on this feedback we selected four new modules for the 2008-2009 academic year. The new modules are more practical in nature and may be better received by the residents.

Self-reflection, narrative medicine and mindful practice are elements needed for successful practice in today’s health care environment. Psychiatric, and other medial educators need to understand the role that training in this area has not only for enhanced patient care, but also for the well-being of our residents. Moreover, training also involves critical components of several ACGME Core Competencies. Although our data did not reveal a significant pre-/post- course difference in survey instruments, there are a couple of limitations that may explain this finding. First, we have a small residency program, which resulted in a small ‘n’. Second, significant change may not be found after brief exposure to a new concept. Further investigation is needed to determine the effectiveness of this curriculum for psychiatric residents.