Mindfulness for Physician Wellness (and Even Your Patients?)

Author: Jennifer Robertson, MD, MSEd (Assistant Professor, Emergency Medicine, Emory University, Integrative Health Coach, Fellow, Integrative Medicine, University of Arizona) // Reviewed by: Brit Long, MD (@long_brit) and Alex Koyfman, MD (@EMHighAK)

You may be familiar with the term mindfulness and perhaps even the concept of mindfulness, but are you aware of the history of mindfulness and the research that has been devoted to it? Reported benefits are many, including reduced anxiety and stress, reduced pain, a more positive outlook, and improved overall well-being (1-4).  Beneficial changes in heart rate variability and decreases in cortisol levels have also been found in those who practice mindfulness meditation (5). Regular mindfulness training has even been shown to change the function of certain aspects of the brain, which may be an underlying reason for its health benefits (6, 7).

What is mindfulness?

Mindfulness refers to the ability to focus one’s awareness on the present moment without judgment of feelings, sensations or thoughts. This includes formal meditative practice as well as the nonjudging awareness of everyday experiences (8).  In contemporary psychology, mindfulness is an approach for increasing awareness and responding skillfully to mental processes that contribute to emotional distress and maladaptive behavior (8). It is essentially a form of mental training that reduces cognitive vulnerability to reactive modes of the mind that may otherwise lead to or exacerbate psychopathology (8).

Mindfulness is rooted in ancient practices and has been integrated into a variety of therapeutic techniques such as acceptance, and commitment therapy, dialectical behavior therapy, mindfulness based cognitive therapy, and mindfulness-based stress reduction (MBSR) (9-12). MBSR was one of the first clinical applications of mindfulness-based therapy. It was originally developed by Dr. Jon Kabat Zinn in the 1970s to help individuals manage chronic pain (9). It is a program that uses a combination of mindfulness meditation, body awareness, and yoga asanas with the aim of increasing mindfulness (13). Typically, MBSR is run across an eight-week course where participants meet at least once a week for a 2.5 hour session. It also includes one eight- hour day over the course, as well as sessions of Hatha yoga and 45 minutes per day of home practice (13).  MBSR has been promoted to clinicians as a safe and effective technique to reduce stress and anxiety in diverse patient populations (13).

Breathing meditation, yoga, and attention training are just a few examples of practicing mindfulness. For example, in a sitting or breathing meditation, an individual maintains an upright posture and attempts to maintain focus on a particular object, sound, smell or most commonly, the breath. When the individual’s attention wanders from the focus, he or she simply notices it without judgement and then attends back to the focus. The process is repeated until the meditation is complete. In a more informal fashion, individuals may try to focus on particular moments throughout the day, using the breath as an anchor. In the state of mindfulness, thoughts and feelings are observed as events in the mind without over-identifying with them. Over time, events are looked at less reflexively and more reflectively (8).

Neuroimaging studies have even found that mind-body interventions such as mindfulness increase gray matter in the brain regions related to emotion regulation, learning, memory, self-referential processes, and perspective taking (14,15). Mindfulness meditation allows for non-reactive acceptance, which is thought to facilitate extinction learning, as well as regulate emotions (6, 16). Extinction learning refers to the steady decrease in a reaction to a habituated stimulus that occurs when the stimulus is presented without reinforcement (17). The hippocampus is a necessary part of the brain that is crucial to extension learning as well as retrieval of memories and regulating emotions. Mindfulness has been shown to demonstrate changes in hippocampal structure and function as well as other parts of gray matter (6,16). In one randomized controlled trial of adults 18-15 years of age, an 8-week mindfulness meditation program helped strengthen hippocampal circuits that are thought to help with extinction learning. By promoting extinction learning, improved resilience and reduced stress and anxiety may result (6).

While much of the evidence for mindfulness was initially anecdotal, recent randomized controlled trials are demonstrating positive evidence that mindfulness may not only help with mental disorders, but with pain control and other physical disorders as well (18-25).  Of note, while there are various types of mindfulness meditation, all are similar in the primary goal to maintain focused attention without added judgement or meaning (8). Thus, while the studies mentioned in this article may vary in terms of meditation types, it should be noted that they all contain elements of mindfulness.

How can mindfulness help me, as a physician or provider?

Stressful situations are inherent in healthcare, and these can negatively impact the mental, emotional and perhaps physical health of anyone working in healthcare (18). Unfortunately, because of the inevitable stress that occurs, healthcare workers may become vulnerable to depression, decreased job satisfaction, burnout, and even suicide (26, 27). Fortunately, mindfulness techniques, including MBSR, may be useful toward ameliorating stress and its associated consequences (18).

While some research fails to find positive effects of mindfulness on healthcare worker’s mental and emotional health (20, 28, 29), there are many studies that have found benefits of mindfulness for those working in healthcare (1-3, 20, 29, 30, 31In one randomized controlled trial, an eight-week MBSR program (2-hour sessions for 8 weeks) was tested on various healthcare providers versus controls. Compared with controls, significant differences were found for perceived stress (27% vs 7%) and self-compassion (22% vs 3%). In addition, the intervention group showed non-significant reductions in job burnout (10% vs. 4%), and distress (23% vs. 11%) and non-significant improvements in satisfaction with life (19% vs 0%). Limitations to this study were that there were low numbers for the intervention group (n=10) and controls (n=18). However, the results point to the value of self-compassion as a potentially important outcome of mindfulness and a mediator for future studies (18).

In another study by Benzo and colleagues, 400 healthcare workers completed questionnaires assessing levels of happiness; self-compassion; mindfulness; and other variables such as exercise, spirituality, and attending wellness facilities.   After adjusting for age, gender, marital status, exercise, and other variables, self-compassion was found to be significantly and independently associated with perceived happiness (30). Similarly, in a randomized controlled trial of nursing students, those participating in a MBSR course (compared with controls) were found to have greater decreases in depression, anxiety, and stress and greater increases in mindfulness (31).

A few studies have not found been as positive concerning mindfulness. However, in these studies some benefits were found, just not for every variable (20, 28, 29). For instance, in a randomized controlled trial of 110 nurses, half completed an eight-week MBSR program while the other half did not. Each participant completed a questionnaire at baseline immediately after the intervention and 3 months later. The intervention group showed decreases in stress and negative affect and increases in positive affect and resilience, but there was no improvement in job satisfaction (20). Another study also found that mindfulness did not improve burnout or life satisfaction. However, it did improve perceived stress in the emotional exhaustion piece (the core component of burnout syndrome) as well as depression, anxiety, and positive affect, and negative affects (29). Thus, while mindfulness may not improve every parameter, it still demonstrates benefit. With the amount of positive benefits and minimal risk, mindfulness does seem a promising intervention to help improve the mental and emotional health of healthcare providers (1-3, 20, 29-31).

How could mindfulness possibly help my patients?

As an ED physician, you may be tempted to get every patient out the door quickly, especially the repeat customers.  However, those with underlying anxiety and/or depression may actually be visiting the ED more frequently (32, 33). Thus, as a clinician, one may want to consider that the anxiety, stress or fear could be contributing to the repeat visits. Consequently, considering referral to a mindfulness-based counselor or suggesting various techniques could be helpful for these patients.

Psychologic stress is known to be a potent trigger of inflammation (34). When one is stressed, the “fight or flight” response is triggered, leading to increased heart rate, metabolism, blood pressure, respiratory rate, and brain waves. Mindfulness and other mind-body techniques have been shown to be effective relaxation techniques, leading to improved heart rate variability, slowed breathing, and even improved markers of inflammation (35, 36).   Given that inflammation is an underlying factor in many disease processes this may be one reason why mindfulness, and other mind-body techniques, may be useful as adjuncts in the management of acute and chronic disease processes.  Studies have demonstrated that mind-body interventions affect gene expression and disease vulnerability by improving response to oxidative stress and associated cellular damage and inflammation (37). Additionally, mindfulness has been shown to have positive effects on health conditions including chronic obstructive pulmonary disease (COPD), back pain, hypertension, fibromyalgia, and pain from diabetic neuropathy (19, 21, 22, 24). In a randomized controlled trial of a 3-month breathing based walking intervention in patients with COPD vs control (both receiving usual care), significant changes in anxiety, depression, dyspnea, and quality of life were found for those patients in the breath-based walking group (22).  In another study of patients with fibromyalgia, a mindfulness program (MBSR) helped reduce clinical symptomatology of fibromyalgia. The program was also noted to have a regulatory effect on the immune-inflammatory system (19). Even those struggling with acute and chronic pain may benefit from mindfulness (23-25). In a study by Lopes et al, a mindfulness-based intervention was studied in 64 nursing technicians with chronic pain. Before the intervention, scores of anxiety, depression, mindfulness, musculoskeletal complaints, pain catastrophizing, self-compassion, and perception of quality of life were quantified.  Scores on these tests were re-evaluated after 8 and 12 weeks of weekly mindfulness sessions.  Overall, the mindfulness intervention reduced the scores of musculoskeletal symptoms, anxiety, depression, and pain catastrophizing (p < 0.001). There were also significant increases in self-compassion and quality of life (25).

As a clinician, even if you do not feel comfortable recommending these practices or referring to specialists who can teach mind-body practices such as meditation and yoga, it may be useful to simply know about them. In a cross-sectional survey of patients presenting to three ED’s in a 4-month period, it was found that many ED patients already use various mind body practices, including mindfulness meditation.  Out of 674 patients, nearly ¾ of patients had used at least one mind-body practice including meditation (35.2%) and yoga (30.6%). In addition, 6.1% of these patients had used some type of mind-body practice for their actual ED complaint. Thus, knowledge of mind-body practices, including meditation, may help better inform ED physicians when making management decisions (37). While these techniques are beyond the scope of this article, other possible mind-body practices that ED physicians may want to know about include Tai-Chi, biofeedback, guided imagery, progressive muscle relaxation, and music therapy.

Simply being a mindful healthcare provider may help patient care. In an integrative review of various studies on the effects of mindfulness on healthcare providers, moderate support was found for improved patient safety, patient treatment outcomes, and patient centered care (38).

Conclusions:

While mindfulness may seem like an “out there” intervention for physicians and patients, there are data supporting its use. While you may not feel comfortable utilizing this technique or even suggesting it to patients, it may be helpful to simply be aware of its use and that many of your patients may be utilizing mind-body techniques to manage their mental, physical, and emotional health.  If one is interested in learning more about various mindfulness techniques, the MBSR website is a good starting point (https://www.umassmed.edu/cfm/mindfulness-based-programs/). If one wants to start his or her own mindfulness meditation practice but is not ready to devote much time to it, then there are several meditation apps that can be downloaded including Insight Timer ™, Calm ™, Headspace ™ and others. Even small amounts of meditation can be helpful (39) so consider starting meditation.

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