Mindfulness for Physician Burnout

By Luke Fortney, MD. Dr. Fortney is Assistant Professor, University of Wisconsin-Madison Department of Family Medicine; he reports no financial relationship to this field of study.

Death by suicide is a significant occupational hazard for physicians.1 This is strongly associated with professional burnout, which is characterized by a loss of emotional, mental, and physical energy due to continued job-related stress. Studies have identified three factors that are independently associated with burnout for both surgeons and internal medicine physicians — hours worked per week, experiencing a work/home conflict within the last three weeks, and how the most recent work/home conflict was resolved.2 In general, up to 60% of physicians report having experienced burnout3 at some point in their career, with up to 30-40% experiencing burnout currently.4 This is particularly concerning given the fact that many aspects of patient care — such as physician self-reported medical errors, lower empathy, early retirement, higher job dissatisfaction, and lower patient satisfaction and treatment adherence — are affected by burnout.5

As the Patient Protection and Affordable Care Act gears up for implementation within the United States, absent from this legislation is consideration about how health care reform will affect physicians, particularly in primary care. Providing insurance to 30 million previously uninsured citizens will increase demand for primary care where an increasing elderly population, decreased supply of primary care physicians, low primary care interest among medical students, poor reimbursement, and increased workload demands from health system employers already add further strain.

Research suggests that physician burnout begins in medical school prior to the clinical years of medical education. A cross-sectional survey administered to third-year medical students in New York found that 71% of medical students met criteria for burnout.6 This is particularly concerning given that suicidal ideation among medical students is nearly double compared to the general population.1 In addition, it is troubling that there is a paucity of intervention research in physician and medical student burnout, noting that very few health employers, medical schools, and residency programs offer any skills or support that adequately address burnout prevention and facilitate well-being.

It is interesting to note that the strongest burnout factor reported by medical residents is a mental attitude of pessimism. Contrary to this, mindfulness meditation teaches practices that cultivate the mental attitudes of acceptance, letting go, non-striving, non-judging, patience, trust, beginner's mind, and forgiveness, among others. Further, the practice of meditation is correlated with lower burnout scores and increased well-being.7 Mindfulness is a fundamental aspect of the meditation experience that reflects the basic and fundamental human capacity to attend to relevant aspects of experience in a nonjudgmental and non-reactive way, which in turn cultivates clear thinking, equanimity, compassion, and open-heartedness.8 Stated as simply as possible, mindfulness means being present with what is happening moment by moment, whether it is pleasant, unpleasant, or neutral. The goal of mindfulness is to maintain fluid awareness in a moment by moment experiential process that helps one disengage from strong attachment to beliefs, thoughts, or emotions in a way that generates a greater sense of emotional balance and well-being. Of all the meditation styles and practices, mindfulness is particularly useful for physician burnout because it has a large and growing corpus of research in the medical literature. It is also non-religious, which allows for wider secular and academic appeal. However, mindfulness has been used in many different religious settings and is not discriminating in this way.

In addition to the many health benefits of meditation — which have been widely documented in the medical literature9 — the teaching and practice of mindfulness for physicians in regard to burnout is adeptly poised to address this problem. Many studies have demonstrated that training in mindfulness reduces anxiety and increases positive affect10,11 while others show benefit in preventing recurrence of depression.12 Research suggests that practicing mindfulness cultivates present-moment awareness that helps reduce medical error and improve patient care. For example, faulty thinking, such as snap judgments, distracted attention, inadvertent stereotyping, and other cognitive traps, leads to critical mistakes in patient care.13 Preliminary research also shows that practitioners who themselves exhibit healthy habits are more effective in motivating patients to make significant positive change in their own life.14 This is also true of health practitioners who themselves practice meditation. In a randomized controlled trial, patients of interns who received mindfulness training did significantly better than those patients treated by interns who did not receive mindfulness training.15 Another study involving primary care physicians assessed the impact of an 8-week mindfulness continuing education course. The 15-month study reported improvements in mindful awareness, burnout, depersonalization, personal accomplishment, empathy, and emotional stability among physician participants.16

To further address burnout among physicians, a study is being conducted using mindfulness education for primary care physicians to help address burnout, compassion, resiliency, and work satisfaction.17 A collaborative online education and resource module (http://www.fammed.wisc.edu/mindfulness) was created and is freely available to provide ongoing support for mindfulness practice and to help clinicians bring mindfulness into the clinical encounter. Given the time demands on medical learners and practicing physicians, it is important that further research and novel curricula explore methods that can teach skills such as mindfulness in ways that are easily and widely accessible, honor time limitations, and are effective. There is a growing interest in research that supports web-based interventions such as this one, with promising results showing significant long-term improvements for mindful awareness, distress, and negative affect following the web-based training.18 Programs and institutional-based approaches that address burnout among physicians are few and far between, and further effort that supports well-being and stress reduction among physicians is needed.

References

1. Dyrbye LN, et al. Burnout and suicidal ideation among US medical students. Ann Intern Med 2008;149:334-341.

2. Liselotte N, et al. Work/Home conflict and burnout among academic internal medicine physicians. Arch Intern Med 2011;171:1207-1209.

3. McCray LW, et al. Resident physician burnout, is there hope? Fam Med 2008;40:626-632.

4. Wallace JE, et al. Physician wellness, a missing quality indicator. Lancet 2009;374:1714-1721.

5. Liselotte N, et al. Physician burnout, a potential threat to successful health care reform. JAMA 2011;305:2009-2010.

6. Mazurkiewicz R, et al. The prevalence and correlations of medical student burnout in the pre-clinical years, a cross-sectional study. Psychol Health Med 2011;July 25.

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12. Teasdale J, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000;68:615-623.

13. Sibinga E, et al. Clinician mindfulness and patient safety. JAMA 2010;304:2532-2533.

14. Frank E, et al. Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med 2000;9:287-290.

15. Grepmair L, et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients; a randomized double-blind controlled study. Psychother Psychosom 2007;76:332-338.

16. Krasner MS, et al. Association of an educational program in mindful communication with burnout, empathy, and attitude among primary care physicians. JAMA 2009;302:1284-1293.

17. Rakel D, et al. Mindfulness in medicine. Explore 2011;7:124-126.

18. Gluck T, et al. A randomised controlled pilot study of a brief, web-based mindfulness training. International J Integrated Care 2011.