Physicians practice putting mind over matter

Despite endless nagging and reminding, a patient with heart disease and diabetes won't take medication. Rather than repeat futile badgering, Edward A. Stehlik, FACP, recommends that the patient not take the medications. It's not a trick, he emphasized, but rather an attempt to create an honest and authentic relationship based on acceptance.

That's one of the key tenets of mindful communication, a practice that draws on meditation techniques to help physicians and others maintain an open and nonjudgmental outlook. Dr. Stehlik, an internist in Buffalo, N.Y. and Governor, Upstate New York ACP, was one of 26 physicians to complete the first of two eight-week sessions of “Mindful Communication: Bringing Intention, Attention and Reflection to Clinical Practice.”

Acceptance does not mean resignation, said Michael S. Krasner, FACP, the program's project director, assistant professor of medicine at the University of Rochester School of Medicine & Dentistry and an internist in the Olsan Medical Group in Rochester, N.Y. Instead, it's a matter of facing reality. “It's about opening our eyes to what's really going on so that we will have a very honest relationship, share our feelings and maybe, with acceptance as a starting point, change everything,” he said.

Much to Dr. Stehlik's surprise, accepting his patient altered the dynamic: the patient started asking more about the medications and decided to take them. Then there's the overall impact. Dr. Stehlik said being mindful helps him stay more focused, which saves time during patient visits, keeps him calmer day-to-day and improves his practice, even after 25 years.

“I'm old school,” he said. “As a traditionalist, I found [mindfulness] pretty amazing … It makes you sharper, more aware, and that can only improve diagnostic care.”

Whether mindfulness works to improve day-to-day patient care is still being tested as other participants bring their techniques back to their offices and the seminar's coordinators gather survey data to evaluate the effects. Regardless of those results, supporters say internists, often skeptical by nature, should consider mindfulness to help them cope with increasing stress and isolation of practicing today.

What is mindfulness?

Mindfulness for physicians is meant to bring awareness back to the relationship in the examining room, rather than have that awareness held captive by the distractions of phone calls and waiting patients.

Dr. Krasner, who has taught mindfulness since the 1990s, defines it as moment-to-moment nonjudgmental awareness of the present experience with receptive attention to ongoing events and with an orientation of curiosity, experiential openness and acceptance. Everyone has it, he said, but the distractions of being future-oriented and feeling bad about the past leaves little attention left for the present moment.

Mindfulness can help physicians face challenges in their personal and professional lives, he said, especially clinical situations that present ambiguous problems with no simple answers.

He traces the entry of mindfulness into mainstream medicine back to the work of Jon Kabat-Zinn, PhD, and colleagues at the University of Massachusetts Medical Center in 1979. The concept spread following Bill Moyers' 1993 “Healing and the Mind” series.

The free program for primary care physicians in Rochester was sponsored by ACP's New York Chapter and funded by a three-year grant from the Physicians' Foundation for Health Systems Excellence. The program, which offers CME credit, met once a week for eight weeks beginning April 2007 for the first group of physicians, with a second group beginning in September 2007. After week six there were day-long silent Saturday retreats. At the end of the initial eight weeks, the participants began meeting monthly for 2.5-hour meetings for the rest of a year discussing such topics as end-of-life and self care.

Because there was some concern that busy internists would not find the time to attend the sessions, Dr. Krasner not only sent out notices but also made office visits to get physicians interested in taking the class. About 75% of those who signed up followed through, he said, noting that word of mouth led to higher registration of 40 people for the second group.

How it works

The first half of each class is spent learning and practicing mindfulness meditation techniques such as the body scan. This involves sitting or laying on the floor while being guided through the experience of sensations, starting with the feet and then moving throughout the body. The challenge is to stay with the guidance, noticing the sensations that are present, while also being aware of distractions such as thoughts.

During the second and third weeks, sitting mindfulness is introduced. By the third or fourth week, mindful movement is introduced using hatha yoga, and walking meditation is practiced. There are home practice assignments, such as the body scan or sitting meditation for 15-20 minutes each day using a guided CD, as well as readings drawn from the medical literature, many from the ACP Press' book, On Being a Doctor.

“The idea is not to get graded for not having a thought,” Dr. Krasner said. “It's about cultivating the ability to pay attention on purpose while becoming intimate with the thoughts that are going on all the time.”

The second half of the class is spent sharing clinical stories from the participants' practice experience through narrative medicine. Participants write for 15 minutes about personal stories related to their clinical practice or their personal lives, following themes such as setting boundaries, teamwork, or attraction to patients. They share their stories in pairs or small groups, then discuss again in the larger group. Listeners are instructed not to analyze, interpret or share their own experiences while listening, but to inquire of the storyteller with an effort to deepen their mutual understanding of the stories.

Appreciative Inquiry, an approach to performance improvement that focuses on what's working rather than on what isn't, is also used. “We're trying to turn away from the usual approach to problem solving,” Dr. Krasner said, by not just focusing on the problem but on the strengths shown through the stories, and how these strengths show up elsewhere in life.

That can be a stretch for some physicians, since they're trained to find out what's wrong, diagnose it and fix it, said Anthony L. Suchman, FACP, a Rochester, N.Y.-based internist who helped design the mindful communication sessions. He likes to use appreciative inquiry in practice by asking patients to share a story about a time when they were feeling particularly healthy, rather than just focusing on risk factors.

“We always ask what's wrong with the patient. The question of what's right is really transforming,” he said.

Mindfulness in practice

It can take a while to understand mindfulness, and the results can be gradual and subtle.

Dr. Krasner noted the experience of one participant who was talking to a very ill patient who said something funny. Through mindfulness she was able to enjoy the humor in the midst of the gravity of the patient's condition, he said.

Robert McCann, FACP, professor of medicine at the University of Rochester and chief of medicine at Highland Hospital, said he's found what he's learned from Dr. Krasner about mindfulness—he and eight other faculty members from the hospital took a similar course from Dr. Krasner a few years before the grant program—has snuck up on him. Now he finds a minute to focus on breathing or makes a renewed effort to give patients his undivided attention.

Like Dr. McCann, who'd always had an interest in meditation, those who took the class might have been sympathetic to the topic to begin with. But it can be hard to keep the momentum going once class is out.

Timothy E. Quill, FACP, said two simple exercises can keep mindfulness in play: First, stopping for two minutes at the start of a session and taking twenty slow breaths with no other distractions can help center a physician for the challenges to come. Second, one or two deep breaths just before entering a room help quickly clear the mind between patients. If one is feeling seriously stuck, and these simple techniques are not helping, then a therapist may be needed to jump start the process, said Dr. Quill, director, Center for Ethics, Humanities and Palliative Care at the University of Rochester Medical Center.

The process also may improve physician health. According to Peter S. Moskowitz, MD, founder and executive director, the Center for Professional & Personal Renewal, Palo Alto, Calif., double-blinded research has shown that people who meditate get sick less often, have lower blood pressure and heal faster. Dr. Moskowitz added that he meditates three to five times a week.

But will mindfulness really make physicians better practitioners? Those running the session hope to find that answer by analyzing surveys given to participants before they started the class, on their first day of training, at the end of the first eight weeks, then 12 months and 15 months later. They want to see if burnout is less at the end of the program and if so, how that affects quality and cost scores, according to Howard B. Beckman, FACP, medical director of the Rochester Individual Practice Association, who also helped put the sessions together.

“If I'm feeling centered do I listen to someone better so I can discover what's wrong with them? So I don't need to do a CAT scan or make a referral for something I can discover if I have enough time and energy to do myself?” he asked.

If there is a connection, it will give weight to arguing for work environments and employers to shape practices that address physician burnout, he said. The analysis of that data and its effect on costs should be available mid-2009.

Is stress inevitable?

For now, it seems as if the factors causing stress are here to stay and, in some cases, worsening: neglected sleep and compartmentalized personal and work lives that begin in medical school and residency, the stress of malpractice, decreasing collegiality opportunities and income, increasing demands of the medical system and, frequently, a drive for perfection and control and resistance to asking for help.

And its symptoms are all too familiar, ranging from moodiness, resentment, anger, exhaustion, and impatience to depression, headaches and other physical symptoms that can lead to burnout.

The good news is that training may change over time—Dr. Krasner has helped create a curriculum at the University of Rochester School of Medicine on mindful practice that rolled out last May and is now required for all third year medical students and residents in most programs. However, the rise of hospitalism and the frenetic pace of internists' practice mean physicians are more and more isolated, a condition that can lead to less collegiality and more stress.

“I used to have friendships with specialists. Now they wouldn't know me if I saw them on the street,” Dr. Krasner said.

Mindfulness means facing that and other harsh realities of practicing medicine today. “You could lament how great it used to be, but [mindfulness] is more about seeing a situation exactly as it is, and then drawing upon what skills do you have to cope with this,” he said.

Dr. Krasner hopes mindfulness training will pay off for physicians in the long run, but is well aware that not all of the practices will resonate with everyone. He talked about one participant who comes over an hour late to each monthly session. That physician explained that while he liked writing narratives, he “didn't do” meditation. That's OK, Dr. Krasner said, as long as something clicks.

“My hope isn't that people will be sitting on a cushion in two years hoping their mind will empty,” he said. “It's more that they have a reconnection with what brought them into medicine in the first place and how to keep that alive amidst all the challenges we're facing.”

Mindfulness and more

How do you deal with stress? Peter S. Moskowitz, MD, founder and executive director, the Center for Professional & Personal Renewal, Palo Alto, Calif., has found the following techniques helpful for healthcare professionals:

• Meditation, including mindfulness
• Breathing exercises for five-10 minutes as breaks at work
• Progressive relaxation techniques to relax portions of body muscles from head to toe; this can take 10-15 minutes and guided tapes can help.
• Guided visualizations in a quiet room
• Humor—listen to funny movies or tapes
• Affirmations—statements often self-written directed to each person's unique personality, read every day
• Healthy eating. Not having candy bars instead of lunch can eliminate mood swings
• Sufficient sleep. When physicians are pushed for time, sleep is often the first to go. If done chronically, that alone can lead to stress and make it harder to deal with adverse events during the day.
• Fun in your life. Put mandatory fun on the schedule at least several times a week.
• Work/life balance. Physicians typically spend too little time with their children, hobbies or sports, often don't have more than one close friend, if any, and may have little or no spiritual life.

Physicians should also remember the traditional advice they give their patients: regular aerobic exercise three to five times per week for a minimum of 30 minutes. “That's perhaps simplest stress buster I know,” Dr. Moskowitz said. “Improving work-life balance is the overall most powerful and effective form of stress relief and burnout prevention.