a study on Stress
Our understanding of the magnitude of physician burnout, its relationship to diminished performance and the development of mental and physical illness is crystalizing. Data now links burnout with diminished physician professionalism, patient outcomes, hospital economics and patient safety. Moreover, burnout appears to be a surrogate measure of distress among physicians. In a national survey of practicing surgeons, alcohol misuse and suicidal ideation were up to 3 times that of the general population. When burnout was present the likelihood increased 25% and 90%, respectively. Among physicians in general, burnout increases the likelihood of depressive symptoms 170%. In surgical trainees, there is alarming prevalence of distress symptoms, with a recent national survey (manuscript in preparation) showing 16% suicidal ideation, 32% moderate to severe depression, 58% high stress and 61% alcohol misuse or abuse among PGY-3s. It has been proposed that chronic and overwhelming stress in the absence of adequate coping skills promotes burnout and associated distress symptoms. It has also been posited that performance deficits, from surgical errors to poor professionalism, derive in large part from the deleterious effects of stress on cognition. Mindfulness mental training, most frequently in the form of Mindfulness-Based Stress Reduction (MBSR, as developed by John Kabat-Zinn), has been shown to protect or enhance cognition, well-being and physical health in multiple clinical populations and in healthy adults. Two decades of research have shown that MBSR and MBSR-based interventions create new habits in the brain subserved by organic, structural changes. Such interventions have been shown to protect cognitive function in pre-deployment marines and incarcerated juveniles; reduce relapse in major depressive disorder; enhance immune function in HIV+ males; reduce PTSD severity in veterans; enhance job performance in inner-city teachers; improve cognitive function and pro-social skills in children; increase professionalism and decrease burnout in PCPs; improve work satisfaction and engagement in numerous populations of health care workers; and diminish psychological stress in soldiers, physicians and professional athletes. This study seeks to demonstrate the feasibility of mindfulness training in surgical Interns while simultaneously providing objective pilot data on the effectiveness of mindfulness training in a randomized, controlled setting. In-coming surgical Interns will be recruited, randomized to mindfulness training or an active control group and undergo psychologic, physiologic, neurocognitive, neuroanatomic and performance assessments at baseline, post-intervention and one year later. Data will inform sample size calculations for subsequent, adequately-powered RCTs and will guide the creation of a feasible formal training model. Moreover, results could significantly impact formal medical training, the mental health of providers at every level, and the overall quality of patient care.
Mindfulness Training to Improve Mental Health, Stress and Performance In Physicians
Burnout, which comprises emotional exhaustion, depersonalization and diminished satisfaction with one's work, has been documented among front-line physicians since 1981. Since then, burnout has been reported in medical students, trainees and every medical specialty examined, including 69% of surgical residents and 40-60% of practicing physicians. The problem is growing: a recent national survey of US physicians showed an 8.9% increase in burnout between 2011 and 2014.
Concomitantly, our understanding of the relationship between physician burnout, diminished performance and the development of mental and physical illness is crystalizing. Data now links burnout with diminished physician professionalism, patient outcomes, hospital economics and patient safety. Moreover, burnout appears to be a surrogate measure of distress and vulnerability among physicians. In practicing surgeons, alcohol misuse and suicidal ideation are up to 3 times that of the general population, but when burnout exists the likelihood increases 25% and 90%, respectively. Among physicians in general, when burnout is present, depressive symptoms are 170% more likely. In surgical trainees, there is alarming prevalence of distress symptoms, with a recent national survey (manuscript in preparation) showing 16% suicidal ideation, 32% moderate to severe depression, 58% high stress and 61% alcohol misuse or abuse among PGY-3s.
It has been proposed that chronic and overwhelming stress, in the absence of adequate coping skills, promotes burnout and associated distress symptoms. It has also been posited that performance deficits, from surgical errors to poor professionalism, derive from stress effects on cognition. Very few studies have examined the effects of burnout on performance among surgeons and surgical trainees, nor have any focused on mediating psychological characteristics in this population. Moreover, while recent studies have described environmental assets that may reduce the risk of burnout and distress, there is very little work testing individual-based interventions among surgeons and no work to date focusing on mindfulness in this population. Interestingly, our cross-sectional national survey of general surgery residents examined psychological characteristics that mediate stress and found that dispositional mindfulness reduces the risk of burnout, perceived stress, alcohol misuse and abuse, moderate to severe depression and suicidal ideation.
In this context, we suggest that purposeful mindfulness training could be a powerful component of stress resilience training among surgeons and surgical trainees. This hypothesis is further supported by the Mindful Surgeon pilot RCT of surgical interns who underwent an 8-wk formalized mindfulness mental training curriculum with pre-, post- and 1 year follow-up assessment in 2016. Outcome measures included burnout, depression, suicidality, stress, mindfulness, executive function testing, circulating biomarkers of stress and functional MRI of the brain and neural circuitry. Data is still being collected and analyzed, but preliminary analysis suggests that the intervention arm manifests less stress and stress deterioration than controls.
We propose to repeat this pilot RCT with greater numbers of participants, although still focusing on the in-coming class of surgical interns at a single institution. Recruitment will happen through email, describing the voluntary opportunity to participate and the details of the study commitment. For those that meet inclusion criteria, baseline assessments will occur during 'Bootcamp Week' which is a mandatory immersion experience for all new surgical interns at UCSF. Assessments include questionnaires to assess burnout, stress, mental health and coping strategies, biologic markers of stress and resilience, executive function, motor skills acquisition and fMRI brain scans. Participants will then undergo the 8 weeks of either intervention or active-control condition and have repeated assessment right after completion. Long-term follow-up with involve re-assessment at 6-months and 1 year.
The significance of studying mindfulness mental training in surgeons and surgical trainees is two-fold: 1) As a process-centered skill with demonstrated effects on psychological well-being, perceived stress, cognitive performance and physiologic health it presents a potential gateway mechanism for providing individuals with a 'universal tool' for challenges across all stages of medical training and practice, including burnout and errors which have been largely immutable problems for the last decade. 2) If efficacy among surgeons can be shown, the social clout of impacting such a high stress and high performance field is uniquely powerful and could further the dissemination of evidence-based mindfulness interventions to a remarkable degree.
The innovation of this work is in bringing a mind-body intervention (mindfulness mental training) to bear in a meaningful way in one of the most traditionally conservative branches of medicine. Additionally, the focus of such training on the cognitive processes that underlie surgical expertise - as a means of improving both surgical errors and surgical training - is unprecedented. In all, the potential for advancing an evidence-based culture change focused on well-being and performance enhancement is remarkable.
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