Mindful Medical Practice: Where are we NOW?

1. May 6, 2011 McGill Programs in Whole Person Care Dr. Patricia Dobkin in collaboration with Julie Irving (PhD candidate) & Dr. Tom Hutchinson Mindful Medical Practice: Where are we NOW?

2. Funding: SSHRC – Julie Ann Irving Programme d’aide aux médecins de Québec-Prends soin de soi- AstraZeneca (CSSS) Students @ McGill Programs in Whole Person Care

3. Questions to ponder: • For whom? • When? • Format? • Workshop • 8-week standard program • Weekend retreat

4. Teach Clinical Initiative Research Med students MDs & HCPs Public McGill Programs In Whole PersonCare Patients

5. Evidence of lack of balanceMedical Students • Students selected in part because of diverse interests and skills • Become very focused on medical training • Little reinforcement for maintaining balance • Non-medical interests put on “back burner” • High incidence of depression and divorce

6. Evidence of lack of balanceResidents • Very long, exhausting work shifts • High responsibility for very sick patients • Little time or energy remains to pursue outside interests • High incidence of depression, suicidal ideation and divorce

7. Evidence of lack of balancePracticing Physicians • Pattern of over-working often continues • Reinforced and rewarded by employers • Little time for interests outside of medicine • High incidence of depression and burn out

8. Evidence of balance or lack there of in YOU please speak with the person next to you and share: One example of balance One example of imbalance

9. Mindfulness for Clinicians What have we done? One day workshops for healthcare practitioners 8 week courses for healthcare practitioners 4 week electives for 4th year medical students One day workshops for 2nd year medical students 8 week course for family medicine residents

10. Published work on mindfulness See Handout

11. Mindfulness-Based Stress Reduction • Kabat-Zinn et al. U Mass. Medical School • Modified for MDs and PhDs • 8-week Group Program (26 hours) • body scan, sitting meditation • mindful yoga, walking meditation • group dialogue • stress management • CDs: home practice manual/exercises • silent retreat day

12. Psycho-educational group format Variation of meditation techniques Didactic material & daily home practice Eight weekly meetings of 2.5 hours Silent retreat between weeks 6 & 7 Core elements from MBSR

13. Unique elements of MBMP • Role plays and other exercises focused on interpersonal mindfulness • Emphasis on communication, Satir stances (also Kramer 2007; Krasner et al., 2009) • Self-care highlighted • Bilingual

14. Mindful Clinical Encounter Social System Medical System A Patient/Person Health Care Professional B C D Disease

15. Role Plays

16. Mixed-Method Concurrent triangulation design Qualitative Grounded Theory Quantitative Pre-Post Research Study 1Study 2

17. Quantitative Measures • Outcomes • The Maslach Burnout Inventory • CES-D/BECK Depression • Perceived Stress Scale-10 • Psychological Well-Being • Process • Mindful Attention Awareness Scale • Self-Compassion Scale

18. Sample characteristics2008-2010 Clinicians (N= 81) • 38 MDs = 48% Family, palliative medicine, pediatrics, etc. • 18 PhDs = 23% • 23 other (RN, MSc) = 29% • 74% women; 26% men • Mean age = 47.6 (SD= 12.5) • 15% pre-MBMP screened + depression (CES-D; BECK)

19. Study 2:Focus Group Questions What are the experiences of health professionals who participated in the MBMP program, including perceived challenges and benefits? How does mindfulness practice effect health professional’s ability to cope with daily and work-related stressors? Does mindfulness practice impact clinical work with patients and/or clients? If so, how?

20. Data Collection Plan over 2 Years (J. Irving doctoral thesis) Cohort 1 Spring 2008 (n = 27) Cohort 2 Spring 2009 (n = 24)

21. Results p < 0.0001Health care professionals Average to low burnout

22. Results p < 0.0001Health care professionals

23. Predictor Well-being βp Model A Perceived Stress -.492 .892 Mindfulness 20.281 .035 Mindfulness x Perceived Stress -.385 .635 Model B Perceived Stress -1.190.495 Self-Compassion 23.755 .003 Perceived Stress x Self-Compassion -.076 .518 Study 1: Regression Analyses Bootstrap

24. Follow-up Questionnaire

25. Standing Yoga

26. Pay attention to what happens to your: • Thoughts • Feelings • Bodily Sensations

27. Data analysis followed the steps outlined by Kruger (2007): Open coding: read the transcripts in their entirety and search for important general, overarching themes. Note emerging themes question by question, and through the transcript as a whole, line by line. Developing coding categories and applying them to the transcripts Create diagrams to illustrate themes and inter-relatedness or processes. Revisit and review sections of data which have been omitted. Systematically report results based upon the research questions. Grounded Theory Analysis

28. CONTEXT Internal and External Landscape ACTION/INTERACTION STRATEGIES CORE PHENOMENON CAUSAL CONDITIONS CONSEQUENCES Focus, Observe, Accept, Change Enhanced Awareness Self & Others Mindfulness Practice INTERVENING CONDITIONS Group Culture & Modeling

29. Example: 1 CONTEXT Internal and External Landscape CORE PHENOMENON ACTION/INTERACTION STRATEGIES CAUSAL CONDITIONS CONSEQUENCES Awareness Inattention Self: Enjoying walk to work Focusing on senses Mindfulness Practice INTERVENING CONDITIONS P12: A very big change…. We discover, I’ve discovered surprising emotions. Like the joy that comes from walking down the street, observing the trees, looking at the clouds. I’ve rediscovered beauty also. The present moment is like a song being sung. Group Culture & Modeling

30. CONTEXT Example: 2 Internal and External Landscape CONSEQUENCES ACTION/INTERACTION STRATEGIES CORE PHENOMENON Self & Other: Create space, let go of my agenda, convey empathy CAUSAL CONDITIONS Awareness “need to fix” Observe, Be with Mindfulness Practice INTERVENING CONDITIONS P6: It’s a new territory for me in my everyday practice that, and I think I am able to listen better to what people have to say because I am trying to really just be there as oppose to “o.k. I have a role to play, I’m here to listen but I have to fix you”. And I noticed that when I have this experience that even if something difficult happened there was a very empathetic interaction. I think I didn’t have a plan that I came in with and I just … I just was present and that worked, by itself. Group Culture & Modeling

31. Data Triangulation Quantitative and Qualitative Mindful Awareness = increased from both perspectives Common Humanity = increased from both perspectives Isolation = decreased from both perspectives Self-Compassion = increased from both perspectives Can this “process” be captured in 8-weeks?

32. Data Triangulation Themes in commonwith other qualitative studies with clinical populations: Importance of group experience and sense of universality P6: There were some times in the past that I felt very isolated and I had difficulties because I thought I was the only one having this problem, but just having a group experience and learning that other people have similar difficulties was so important. I am not alone. [n=19] Centrality of acceptance P25: As for me, yes. I have a tendency towards constant self-criticism because I would like to be perfect. More and more, I accept myself the way I am, because this is who I am. [n= 12] Some degree of frustration and/or distress identified as part of learning process P13:When you do a lot meditation its kind of, you are kind of like cleaning out the drawers and you notice a lot of stuff that comes up. Some of it is great and some is negative memories, things, and emotions that come up and when they’re on there way out, you know, it’s kind of like doing a detox. [n=14]

33. Process themes uniquely highlightedby health care professionals: PerfectionismP24: “Since health care workers seek perfection… I wouldn’t allow myself to make any mistakes while meditating. I had to repeat to myself that I didn’t have to be perfect here”. [n=10] “Helping/Fixing mode”P3: As a clinician, I always had a hard time seeing what my role was, even though I was told we weren’t fixing anything, I always felt that my patients were coming to me to have something fixed. And my expectation of myself was that I was supposed to do something. They were coming to me for a reason and if they are not getting better then I’m not doing something. And I think I came to realize this more and more and it kind of confirmed, like I started to realize that part of my job was to be there with patients... this kind of confirmed for me just being there in the present moment and with their experience is, is very powerful. [n= 8] Other-focus P17: It made me realize how good I am at listening to others… Also, that listening to others is kind of a way of not talking… when I was talking about something that was difficult in the group, as soon as my partner started to talk I forgot all the difficult thing that I was talking about. So I realized, this is a great way not to think of a difficult thing when you are focused on the other. And so that became very clear to me, that there may be a reason why I am such a good listener. [n=7]

34. Awareness of Breath

35. Sample characteristics (2009-11)4th year medical students (N= 46) “Physicianship” elective 2009: n = 15 2010: n = 17 2011: n = 14 Modified to fit elective schedule (1 month) Shorter meditation CDs

36. Medical students’ results (n=46) Significant pre-post changes: Self-compassion Mindfulness Stress * p<.007 ** p<.0001

37. Physicianship 4 (INDS 420) Medicine & Society elective evaluation

38. Physicianship 4 (INDS 420) Comments • “I think there should not be a cap to the size of this class. Every student who wants this opportunity should be allowed to choose it…” • “Excellent class. Only minor change I would request it to leave out breaking the silence during the retreat day and let us leave in silence to break the silence in our own time.” • “Positive impact on my perspective and acceptance. I hope to carry these skills with me throughout my practice. Would like more yoga. […] Enjoyed SIM Centre too.”

39. MERCI Drs Gough et Rajotte La Pratique médicale et la pleine conscience Un programme pour les résidents en médecine en collaboration avec le Centre de santé et de services sociaux des Faubourgs. * p<.001 ** p<.002 *** p<.006 ****p<.005 N=15

40. Questions to discuss: • For whom? • When? • Format? • Workshop • 8-week standard program • Weekend retreat

41. Where to NEXT? • SIM centre assessment of communication • Weekend retreats (next week in Ottawa) • Monthly follow-up 2 hour classes • Conference workshops (Bromont 09/2011) • Canadian Space Agency • Collaboration with Dr Robert Béliveau • Other?