20/1/2014

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

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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 technicalmanual 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

RESILIENCE

• • • • • • • • • •

• • • • • • • • • • •

Withdrawn Emotionally exhausted Going through the motions Worn down, brittle Cynical, hopeless Hypercritical Brittle Feeling ineffective Becoming more rigid Treading water

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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What causes burnout? Balance

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

Career fit Overwork Work / home

Work Environment

Unsupportive Competitive Productivity pressures Too many demands Not enough time Too much change Low control / high responsibility

Physical Sleep Pain Illness

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

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, selfdeprivation, entitlement

Excellence

Perfectionism, invincibility, hiding errors

Curative competence

Omnipotence, imposter syndrome, selfdeprecation

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, selfdeprivation, entitlement

Reframing, balance, gratitude

Excellence

Perfectionism, invincibility, Self-compassion, reflective hiding errors self-questioning

Curative competence

Omnipotence, imposter syndrome, selfdeprecation

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

CAREER FIT

20% Shanafelt Arch Int Med 2009

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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 intrapersonal and interpersonal 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) Mindful practice

Quality of caring ( empathy, compassion, responsiveness)

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 Figure 1: A model of mindful practice, narrative and appreciative inquiry and their effects on communication, physician well-being and clinical outcomes

Mindful practice

Greater self-awareness Lower reactivity

Narrative

Contextualize to particular encounters and communication challenges

Appreciative inquiry

Building on strengths to find new solutions

Increased attentiveness, responsiveness and presence

Improved physician self-efficacy, vitality satisfaction, and confidence Reduced physician stress and burnout

More effective communication with patients

Improved patient satisfaction Improved practice efficiency

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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 Depersonalization 0.45 Personal Accomplishment 0.44

Mindfulness: Total 1.12 Observe 1.03 Nonreact 0.88

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