1. Mindfulness in Medicine: Practical Tools for Physician Self Care
American College of Physicians, Illinois Chapter Meeting
November 17, 2017
Rupel Dedhia, MD
Assistant Professor
Division of Internal Medicine
Clerkship Director, Primary Care Clerkship
Rush Medical College

2. Disclosures I do not have any conflicts of interest to disclose
I do not have formal training in psychology or mental health
I am simply a doc that is seeking to experience joy, compassion, and gratitude in my daily life

3. Objectives
Utilize the Professional Quality of Life (ProQOL) scale as a self assessment tool
Define Mindfulness and Mindful Practice
Describe how mindfulness can be used as a tool to address burnout and cultivate compassion
Recognize how mindfulness can enhance the physician-patient relationship
Incorporate a set of simple mindfulness practices into your personal life and professional work

4. Individual Self Assessment: Professional Quality of Life Scale (ProQOL)
A 30 item self report measure of the positive and negative aspects of caring
The ProQOL measures Compassion Satisfaction and Compassion Fatigue
Compassion Fatigue has two subscales
Burnout
Secondary Trauma
Instructions:
Take about 5 minutes to complete the survey
Follow the instructions to score each section

5. Categories of ProQOL Compassion Satisfaction Compassion Fatigue
Positive aspects of working as a helper
Compassion Fatigue
Negative aspects of working as a helper
Burnout
Inefficacy and feeling overwhelmed
Work-related traumatic stress
Primary traumatic stress direct target of event
Secondary traumatic exposure to event due to a relationship with the primary person
Beth Hudnall Stamm,

6. Complex Relationships
Professional Quality of Life
Compassion Fatigue
Compassion Satisfaction (ProQOL CS)
Work Environment
Client Environment
Personal Environment
Traumatized by work
Secondary Exposure (ProQOL STS)
Primary Exposure
Frustration Anger
Exhaustion
Depressed by Work Environment
(ProQOL Burnout)
Beth Hudnall Stamm,

7. ProQOL: A validated tool
The ProQOL is the most widely used measure of the positive and negative aspects of helping in the world
The ProQOL has proven to be a valid measure of compassion satisfaction and fatigue
It has been used for over 15 years
The measure was developed with data from over people
Beth Hudnall Stamm,

8. Physician Burnout Defined
Maslach and Colleagues Definition
Emotional Exhaustion (losing enthusiasm for work)
2. Depersonalization (treating people as if they were objects)
3. Low sense of Personal Accomplishment (having a sense that work is no longer meaningful)
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996

9. 400 US physicians are committing suicide annually
Increased medical errors
Diminished quality of medical practice
and professionalism
Decreased patient adherence to treatment plans
“Doctors are stressed, burned out, depressed, and when they suffer, so do their patients”
Time Magazine. Sept 7, 2015

10. Shanafelt et al. Mayo Clin Proc. 2015; 90(12):1600-1613

11. Benefits of Fostering Resilience
Personal
Professional
Reduce Burnout and identify signs of burnout early
Increase compassion and empathy
Reconnect with the joy and purpose of practice
Improve physical and mental health
Less staff turnover
Reduce costs of recruiting and replacing burned out physicians
Increase patient satisfaction
Decrease medical errors
Improve work environment
Less disciplinary action
www. stepsforward.org

12. Burnout Prevention Measures
Mindful Meditation
Development of Self-Awareness Skills
Practice of Self-Care Activities
Reflective Writing
Continuing Educational Activities
Kearney et al. JAMA, March 18, 2009; 301:11

13. What is Mindfulness?

14. Further exploration into mindfulness and mindful practice
Lowering one’s own reactivity to challenging experiences
Notice, observe, and experience bodily sensations, thoughts, and feelings even if unpleasant
“Not being on autopilot”-acting with awareness/attention
Focus on experience, not on labels or judgments applied to them
Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians
Krasner et al. JAMA. 2009;302(12):

15. Self Awareness+Mindfulness=Self Care
Self Awareness+Mindfulness=Self Care (Gasping for air versus Learning to breathe underwater)
Low self awareness:
Lose perspective
Increased stress in work environment
Empathy becomes a liability
Risk of compassion fatigue and burnout
Enhanced self awareness:
Development of dual awareness to attend to needs of patient, work environment, and one’s own subjective experience
Greater job engagement
Less stress in work environment
Empathy is mutually healing connection with patient
Increase compassion satisfaction and emotional availability
LEADS to increased self care
Kearney et al. JAMA, March 18, 2009; 301:11

16. Let’s Practice! Mindfulness: Soft Belly Breathing Exercise

17. Incorporate breathing exercises in the office
At the start of the clinic day…
While checking a patient’s BP….
Before going into the next patient’s room…
During the patient visit….
Start of the clinic day, before looking at schedule or agenda, take first 5 minutes to start the breathing exercise
While checking a patient’s BP, ask patients to breathe slowly through their nose and mirror the patient’s breathing with your own
Before going into the patient’s room, pause and bring your attention to the sensation of your breathing for 2 to 5 breaths
Use breathing exercise as a way to help center the patient to their visit (avoid stress of rushing late, frustration at front desk, wait time, etc)
Kearney et al. JAMA, March 18, 2009; 301:11
University of Wisconsin Department of Family Medicine and Public Health Mindfulness in Medicine Program

18. The Promise of Listening
We do not believe in ourselves until someone reveals that something deep inside us is valuable, worth listening to, worthy of our trust, sacred to our touch.  Once we believe in ourselves we can risk curiosity, wonder, spontaneous delight or any experience that reveals the human spirit.               ~e.e. cummings   
How often have you found yourself in a conversation at lunch or dinner; sitting in a meeting at work; or talking to a friend or partner and realize you have no idea what was just said?  If you are anything like the average person, it happens every day (probably more times than you are willing to admit).  You might even be interested in what’s being said but your mind has carried you off on one of its wanderings–into the past or future, to something that’s bothering you, or to your to-do list.
Our minds are often scattered and unruly, which is why the practice of mindfulness can be so important in meaningful, attentive conversation.  You have to be present in order to listen and take in what is being said.  You also have to be listening without your own agenda and without being busy formulating what you will say next. 

19. Mindful Listening
Mindfulness is a wonderful skill to practice when you are in any situation that requires listening. 
In any conversation, you can use the person that’s speaking as your “object of mindfulness.” 
Pay full attention to what he or she is saying. 
When your mind wanders away from what is being said, immediately and without judgment bring yourself back to the words of the person speaking.  
Repeat those instructions as many times as necessary.  You will eventually strengthen your mental musculature to stay more focused and aware
he Mindful Listening practice is a meditation that’ll help you become more aware of your mind and your mental habits during conversation. As you become more aware of your mental habits in your day to day conversations, you’ll also have more power to change it. Here’s how this meditation works. To do this exercise, you’ll need a friend, family member or co-worker. You’ll switch off with one another, each person taking turns to speak. You’ll each speak for 3 minutes, uninterrupted. When you’re in the speaker role, all you need to do is talk for 3 minutes. The topic doesn’t matter, but do try experimenting with different topics. You don’t have to fill the entire 3 minutes. If you run out of things to say, just stop speaking and sit in silence until you feel like talking again. Your turn is over when 3 minutes is up. You’ll want to switch between speaker and listener roles at least a couple times. In this meditation, the more active role is actually the listener’s. When you’re listening, your role is to be mindful. Put your attention on what the speaker is saying – as well as on your mind’s inner dialogue. The most you’re allowed to say when listening is “I see” or “I understand.” Take these 3 minutes to really notice how your mind works when you’re in communication. For example: Do you feel the urge to share your own, possibly impressive story?
Do you feel the urge to offer advice?
What emotions are you experiencing?
Are you “trying” to do anything? Are you trying to get them to like you or trying to do the exercise right?
Are you making any assumptions?
What are the unspoken qualities in the interaction?
Whatever mental tendencies you notice during this meditation, there’s a good chance they’re mental tendencies you experience on a regular basis. In everyday life, when everything’s moving at a fast pace, it’s difficult to be mindful and spot these tendencies. By spotting them in an interpersonal meditation like this, you open up the possibility of noticing them in real-time in the real world. Then you can start to change these habits, if you choose to do so.
Beckman et al. Acad Med. 2012

20. Let’s Practice! Mindful/Conscious Listening
Choose a partner, identify one as the speaker and the other as the listener
Speaker: Answer the question-Talk about a time when work took priority over something else you valued and talk about your feelings and emotions surrounding this episode. You will have 2 minutes to speak
Listener: Role is to be mindful; pay attention to what the speaker is saying. You are not permitted to speak, but can offer gentle nonverbal cues-slight nod or smile
You will be notified when 2 minutes are complete, then switch roles
 Do you feel the urge to share your own, possibly impressive story?
Do you feel the urge to offer advice?
What emotions are you experiencing?
Are you “trying” to do anything? Are you trying to get them to like you or trying to do the exercise right?
Are you making any assumptions?
What are the unspoken qualities in the interaction?

21. Reflection on Listening
Did you feel the urge to share your own, possibly impressive story?
Did you feel the urge to offer advice?
What emotions were you experiencing?
Were you making any assumptions?
What are the unspoken qualities in the interaction?
Whatever mental tendencies you notice during this meditation, there’s a good chance they’re mental tendencies you experience on a regular basis. In everyday life, when everything’s moving at a fast pace, it’s difficult to be mindful and spot these tendencies. By spotting them in an interpersonal meditation like this, you open up the possibility of noticing them in real-time in the real world. Then you can start to change these habits, if you choose to do so.

22. “Practice in Your Practice”
Pause: Stop, Take a Breath, Drop in
Recognize clutter that accumulates in the mind’s thoughts during a busy clinic day and drop beneath it to focus on the patient you are about to see
Presence: Drop in, Become aware of what is happening at that moment, notice thoughts, feelings, emotions. Stay present without reacting
Opportunity to be fully present in the moment, non-judgmentally with the patient you are serving. Allows for more authentic understanding of their needs
Proceed: Using mindful speech and action to respond skillfully, compassionately, and with positive intention to whatever needs attention in this moment
Create a health plan based on obtaining insight into your patient’s needs during “presence”
Focus more on what is right with the patient compared to what is wrong with them
Use a goal or solution driven action plan towards health creation plan
University of Wisconsin Department of Family Medicine and Public Health Integrative Medicine Program: Mindfulness in Medicine

23. Example of Health Plan
Health goal: To reduce the risk of a heart attack
Medications: Continue on you Metoprolol 50 mg daily and your statin, simvastatin 20 mg at bedtime.
Add fish oil (EPA + DHA=1000 mg), 1000 mg daily.
Review and incorporate the DASH diet: DASH stands for Dietary Approaches to Stop Hypertension and consists of foods high in potassium, magnesium and calcium. These include fruits and vegetables, nuts, seeds and beans. It is low in dairy, animal meat, saturated fat and sweets. It has been found to reduced blood pressure by 11.6 points systolic (top number) and 5.3 points diastolic (bottom number) two weeks after starting.
After reviewing your cardiac risk calculator, your 10 year risk of heart disease is 10%. We can reduce this to 2% if we can lose weight and increase your good (HDL) cholesterol.
To Increase the good cholesterol (HDL: Increase aerobic exercise, 40 minutes most days of the week. You mentioned that you enjoy walking your dog in nature. This is a great opportunity to use this time to get your mind more focused on the beauty in nature while enhancing your cardiovascular exercise with a pedometer. Consider wearing this daily and shooting for 10,000 steps a day.
Maintain appropriate weight. As little as 8 lbs of weight loss can raise HDL. For every two pounds of weight loss the HDL rises by about 1%. We agreed to set a 6 mth weight loss goal of 10 lbs (1-2 lbs a month).
University of Wisconsin Department of Family Medicine and Public Health Integrative Medicine Program: Mindfulness in Medicine

24. Mindful Eating

26. Basic Principles ASK: start simple GRATITUDE DINE
Why am I eating now?
What am I eating now?
What else am I doing now?
GRATITUDE
DINE
CHEW, CHEW, and then CHEW
ENGAGE YOUR ATTENTION
Engage attention-when eating-begin to notice mental chattery and redirect experience to your dining

27. Truffle: Fruit Exercise
Let’s Practice!
Truffle: Fruit Exercise

28. Gratitude=Compassion
Gratitude leads to positive emotions and physical well- being
The feeling that occurs when a person attributes a benefit they have received to another
Helps to reduce fear and self-doubt
A form of Loving-Kindness Meditation
Dr. Amit Sood, Mayo Clinic
Sood, A. “Mayo Clinic Guide to Stress Free Living”

29. 5-3-2 plan to bring joyful attention to your life
5 people Morning Gratitude Exercise 3 Minutes of Attention 2 Seconds of Kindness
So let’s sit with eyes closed, and I’ll share with you how I try to wake up every morning.
Imagine you’re waking up this morning and you become aware of yourself and the world around you.
Now think about the first person in your life that you want to be grateful for, and bring that person’s face in front of your eyes. And then send your silent gratitude to that person.
Choose your second person, and go back to the first memory of when you saw this person. And then send your silent gratitude.
Think about someone who has passed away, whom you loved. Give that person a virtual hug, and then send your silent gratitude.
Go back in time and look at yourself when you were eight years old. And then send silent gratitude to your eight year old self.
And then you can open your eyes.
For the first 3 minutes you meet your family or colleague (upon returning home)-meet them as you would a long lost friend, rssolve not to nag or change any behavior at that time, but simply to ask about their day and how they are feeling
The first 2 seconds when you see someone, send them a silent “I wish you well”-this combats our mind’s internal reaction to form judgment and prevent that from happening
www. Stressfree.org
Dr. Amit Sood

30. References
Becman et al. The impact of a program in mindfulness communication on primary care physicians. Acad Med Jun; 87 (6): Epstein, R. Mindful practice. JAMA. 1999; 282 (9): Kearney et al. Self care of physicians caring for patients at the end of life: “Being connected…a key to my survival.” JAMA 2009 March 18; 301(11). Kearney et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians JAMA 2009 March 18; 302(11) Shanafelt et al. Mayo Clin Proc. 2015; 90(12):
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996