Article In Brief
Neurologists who participate in mindfulness training seminars discuss the personal and professional benefits.
For Frederick J. Marshall, MD, chief of the geriatric neurology division at the University of Rochester School of Medicine and Dentistry (URMC), mindfulness is the foundation of his career satisfaction.
“At the end of a long day of seeing patients, I feel sort of all used up, but not empty,” he said, explaining the feeling that comes with working in a full and busy practice.
But, he added, the perspectives and insights he has learned from applying what he has learned from the mindfulness practice programs at his academic medical center have had an impact on his overall well-being. “Often, my work now is actually vitalizing to me,” he explained.
For his colleague, Heidi B. Schwarz, MD, FAAN, professor of clinical neurology at URMC, meditation is an almost daily ritual to support mindfulness throughout her workday.
Giuseppe Erba, MD, professor emeritus in the URMC neurology department, was retired when he attended a four-day mindful practice workshop sponsored by the university. “It was a transforming experience,” Dr. Erba said. “When I came back home, I felt I was deeply changed inside in terms of my perspective.” Two years later, he attended a second workshop. “It was also transformative,” he said.
In the search for solutions to the burnout epidemic among health care providers, mindfulness and its correlate, meditation, are often recommended as activities that physicians and others can undertake to increase their resilience during this difficult period in the practice of medicine.
At the same time, such advice is often derided. Skeptical clinicians wonder how they can be expected to make time for one more obligation and why they are being asked to “zen out” to cope with untenable working conditions.
In interviews with Neurology Today, five physicians who embed mindfulness throughout their professional and personal lives answer those questions. Practicing mindfulness, they said, increases self-awareness and resilience, strengthens communication and relationships, and improves patient care, all of which lead to well-being.
That said, clinician mindfulness was never intended—and should not be expected—to solve health care's burnout crisis.
“Mindfulness is not the solution to physician burnout at all,” said Mick Krasner, MD, co-director of mindful practice programs at URMC. “The solution is really looking at the whole structure of medicine and the systemic factors that are contributing to burnout.”
Mindfulness, Mindful Practice
Meditation and mindfulness, embedded in US popular culture for at least three decades, are sometimes caricatured as a beatific individual in the lotus position, appearing to levitate in escape of life's problems. That's not what Dr. Krasner and his colleague, Ronald Epstein, MD, co-director of URMC's mindful practice programs, are talking about.
Both are practicing physicians—Dr. Epstein practices family medicine and palliative medicine; Dr. Krasner is a primary care physician—and they train clinicians to bring mindfulness to their interactions with patients and professional colleagues. Meditation is practice for establishing a habit of mind—mindfulness—that permeates personal and professional life, Dr. Epstein said.
“We promote mindfulness for clinicians in medical settings when they're with patients, when they're in the operating room, when they're dealing with tragedy or difficulty,” he said. “It's the ability to pause, to assess a situation, and decide where they want to throw their weight.”
Mindfulness allows a physician to respond thoughtfully to a situation, rather than react on auto-pilot.
“It is a capacity for being attentive, being curious, adopting what's called a beginner's mind and being present, all of those qualities that are valued in clinicians,” he said. “No one really talks about how you get those qualities and I don't think they're necessarily things you're just born with. You can actually cultivate them.”
Dr. Epstein became interested in mindfulness more than 20 years ago when, seeking to define excellence in clinical care, he realized that easy measures of a clinician's work are inadequate. “If you were going for surgery and your surgeon told you that they did very well on their boards, would that give you a lot of reassurance? For me, no,” he said. “I am interested in ‘Do you pay attention? What happens when things go wrong? What qualities of mind do you bring to your work that might make you more effective at what you do?’”
Dr. Krasner, meanwhile, was inspired by the Mindfulness-Based Stress Reduction (MBSR) program, developed at the University of Massachusetts Medical Center for individuals with pain, stress, and other chronic conditions. His own father embraced MBSR after a diagnosis of pancreatic cancer and lived for nearly three years, much of the time with a good quality of life, instead of the few months predicted at the time of his diagnosis. Shortly thereafter, Dr. Krasner completed training in MBSR and has taught its techniques to nearly 2,000 participants, including more than 600 health professionals, as well as patients and medical students.
In 2007, Dr. Krasner, Dr. Epstein and colleagues created a yearlong curriculum and trained 70 Rochester-area primary care physicians in the use of mindfulness meditation, self-awareness exercises, narratives about clinical experiences, and other techniques. Pre- and post-tests showed that participants improved on measures of mindfulness, burnout (as measured by emotional exhaustion, depersonalization, and personal accomplishment); empathy; and conscientiousness, among others.
Subsequently, they developed URMC's Mindful Practice program—four-day and five-day retreat-like workshops that have been attended by more than 1,000 medical educators, physicians, and other clinicians around the world.
Dr. Marshall, a member of the Mindful Practice faculty, co-facilitates these residential trainings. Despite the research findings, the initial motivation for the program—learning to practice mindfully with patients—has not been usurped by a focus on mitigating burnout, he said.
“It turns out that there's a kind of felicitous synergy between practicing mindfully and being resilient,” he said. “Wellness, for the clinician who practices mindfully, is one benefit, but it's not the only benefit.”
1,000 Clinicians Trained
Participants in Mindful Practice workshops learn about and engage in three techniques that support mindfulness: formal meditative practices, including yoga; narrative medicine—the creation and sharing of stories that reflect on meaningful experiences one has had as a physician; and appreciative interviews, designed to help participants alter habitual patterns of thinking by discovering and recognizing their strengths and resources.
The events start with a “mindful salon” in which participants gather in a series of small groups to discuss a question, such as “What is it about you and your career at this juncture that brings you to this place?”
“At the end of a long day of seeing patients, I feel sort of all used up, but not empty. Often, my work now is actually vitalizing to me.”
—DR. FREDERICK J. MARSHALL
“The first welcoming evening is kind of a getting-to-know-one-another, but around an invitation to think deeply and intentionally about what our calling is and what it is that first brought us to the table.” Dr. Marshall said.
For the next three or four days, depending on the workshop, he and other faculty members lead participants in formal meditation practice periods and didactic presentations about themes, such as witnessing suffering, coping with medical errors, or working with uncertainty. After each presentation, participants break into small groups to discuss and practice “deep listening” of one another's perspectives.
Participants are encouraged to consider ways they can use the new skills and information to increase mindfulness in their daily work and, if possible, to find a community in their institution to support their commitment to mindful practice, Dr. Marshall said.
For Dr. Erba, who researches seizure disorders at URMC and a research institute in Milan, Italy, the most important discovery of his first workshop was that meditation practice is doable.
“It is just making the effort of sitting quietly and trying to put to silence the old (narratives) that the mind keeps repeating and instead concentrating on the joy of being alive, of the body functions that are necessary every instant to maintain life, and of all the signals that come to our sensory organs,” he said.
He returned for a second workshop, where his main takeaway was how yoga practice supports mindfulness.
“Self-awareness, including of your body, is very important, and that includes feedback from your body parts,” he said. “Now I try to have balance between meditation and body exercises, which I think are equally effective.”
For Patients and Providers
The toll of caring for people with neurodegenerative disease started weighing on Dr. Schwarz after about two decades of practicing neurology. Long-term patients were counting on her and she had no new interventions to offer.
“I was feeling inadequate, sad, frustrated, burned-out, like ‘I would much rather take care of somebody who is a one-and-done than this kind of situation,’’’ she said. “And yet, I felt so connected to these people.”
In the mid-2000s, she was invited to participate in a URMC mindfulness training program. She seized the opportunity, hoping that it might reframe her way of caring for her patients and also learn some techniques that her patients could use on their own behalf.
In the years since, mindfulness and meditation have helped her keep the challenges of medical practice in perspective.
“As I see many of the changes occurring in medicine locally or nationally and feeling that priorities aren't in the right place, this helps to re-center my focus on just me and the importance of having my own right priorities,” she said. “It empowers me in that regard.”
Dr. Schwarz now specializes in headache medicine, and she encourages her patients to use mindfulness techniques as part of their treatment plan.
“What I found is that these great treatments really only work to their best capacity if I also address these issues of mindfulness and self-care with my patients,” she said. “That actually is the initial focus of my visits with patients.”
Like others interviewed for this article, Dr. Schwarz said the biggest satisfaction of her practice was her relationship with patients—the very thing that Dr. Epstein and Dr. Krasner were focused on when they designed mindful practice. A resident was shadowing her recently when a difficult patient—“he likes to manage his own medication and he has a lot of comorbidities”—came for a visit.
“I'm talking with him, and he turns to the resident and says, ‘You know, I don't have this kind of experience with any other doctor who sees me. She knows me. She cares about me. I share things with her I would never share with anyone else,’” she said. “If that isn't an affirmation of what makes a good doctor, and what makes doctoring a meaningful experience, I don't what is.”