For the frequently stressed out emergency physician, devoting time to focusing could help relieve some of the profession’s occupational hazards.
INTRODUCTION
Let’s face it. The topic of burnout has becoming increasingly more prevalent both in academic literature and general news.(1, 2) As emergency physicians, we seem to be even more at risk than physicians in other fields.(2) Large patient loads, limited control over work environments, long hours and difficult cases may all contribute to increased stress and burnout in healthcare providers.(3)
Anxiety, depression, substance abuse and suicide have also been considered “occupational hazards” for medical professionals.(3, 4) Without adequate coping mechanisms, personal health and wellness problems may develop and even persist long-term. On occasion, some turn to the “easy” methods of coping, such as excessive alcohol consumption, over-eating or even drug use. However, these may be dangerous and are certainly not helpful in the long-term.(5-7) So, what can be helpful? Besides proper diet, exercise and sleep, one tool that may be helpful is the practice of mindfulness.
WHAT IS MINDFULNESS?
Mindfulness means being attentive to one’s thoughts, emotions, senses or surroundings as they exist at any moment.(8) It is based upon Buddhist psychology, but it also shares ideas rooted in various philosophical and psychologic traditions such as Greek philosophy and existentialism. While there is no formally agreed upon definition of mindfulness, one working definition is: “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment by moment.”(9)
Mindfulness simply means being present in the moment, rather than doing one thing, but thinking about another. Mindful meditation helps us to focus on the present moment and accept reality. This reflection may help us deal effectively with our feelings and make difficult decisions based on our own belief systems and values.(8)
Overall, mindfulness has been found to demonstrate psychologic, somatic and behavioral benefits. Awareness of the present moment is thought to reduce impulsive or defensive reactions to unsettling experiences, increase self-compassion and promote development of insight into oneself and the human condition.(3, 8)
Other benefits include improving tolerance, patience, trust and empathy. There is also developing evidence that mindfulness-based programs may promote overall well-being, help with depression and decrease levels of burnout.(3, 8, 10) One study found that a 15-month mindfulness-based therapy program helped up to 75% of participants eliminate their anti-depressant medication use.(11)
PRACTICING MINDFULNESS
Meditation is the primary way that mindfulness is cultivated.(12) However, there are two general methods to practice meditation and these include both formal and informal methods.(12) Formal methods mean taking regular, extended periods of time to practice mindfulness, such as via guided meditations or yoga. Informal practice means being mindful in every aspect of one’s waking life. This can mean simply paying attention to one’s present experience without judgement.
For instance, one can become more aware of his or her thoughts or feelings by taking deep breaths and maintaining sustained attention on deep breathing. This allows one to bring attention back to the breath and the situation, without judging any other thoughts that come to mind.(13)
Note the goal is not to suppress one’s thoughts, but rather simply acknowledge the thought or sensation nonjudgmentally so that focus can be re-directed. Formal and informal methods go hand in hand with each other and both may be helpful for developing full awareness.(12)
For the emergency physician, mindfulness can be helpful in a variety of ways. The informal method can be helpful for getting back to moments during a shift. While caring for a patient, a physician’s mind may be occupied with the patient next door, or a lecture that he or she is giving the following week. He or she may also be occupied by other thoughts, such as stressors at home or errands that need to be run after work.
By taking a few deep breaths and purposefully focusing attention, one can center his or her thoughts back to the patient at hand, the note he or she is completing, or any other single moment in the day. This helps to reduce anxiety and regain focus.(12, 14)
Formal, regular meditation helps one to practice focusing attention. This is specifically via deep breathing, but it can be on any single object of attention.(12) The single object may include a wall, a lamp or chair. Regular meditation can be done with the eyes open or closed and can also be done via other modalities such as yoga. Meditation is, really, less about the breath (or any particular object) and more about developing one’s attention (via the breath or object) with greater stability. Gradually, one develops the ability to focus attention easily with more awareness and less judgement.(12) Over time (minimum several weeks), a regular mindfulness practice may even alter brain chemistry, which is thought to help reduce anxiety and depression, regulate emotions and improve stress levels.(14, 15)
One randomized control trial evaluated the effects of an eight-week mindfulness program on frontal brain EEG (electroencephalography) activity in corporate employees. Overall, the authors found that left sided anterior activation of the brain was increased in the meditators as compared to the non-meditators (16) This area of the brain is associated with positive emotions such as joy and content.(16)
Another study also evaluated an eight-week mindfulness program on the brain, however it looked at changes in functional connectivity of the brain using functional connectivity MRI (fMRI).(17) Healthy women were randomly assigned to participate in the mindfulness program. After eight weeks, fMRI imaging (1.5T) was obtained and independent analysis was performed to investigate changes in functional connectivity.
Overall, compared to the control group, the mindfulness group showed several changes in functional connectivity associated with improved attentional focus, heightened sensory processing and better reflective awareness of experiences.(17)
Finally, increased gray matter densities in several areas of the brain have also been seen in patients who undergo mindfulness training.(18-20) One study evaluated anatomical MRI imaging in participants both before and after an eight-week mindfulness-based program. After the mindfulness program, the authors found increases in gray matter density in several areas of the brain, most notably in areas involved in learning and memory, emotional regulation and perspective-taking.(18) Other studies have found similar results in changes in gray matter densities after mindfulness-based programs.(19-20)
HOW CAN MINDFULNESS BE HELPFUL FOR THE EMERGENCY PHYSICIAN?
Mindfulness might seem complicated and too time consuming for your busy schedule, but meditation for eventual improvement in reducing stress and improving awareness does not have to be time consuming or taxing. Formal meditation can be done in less than five minutes per day and informal practices can be done intermittently through one’s day. Let’s use the following cases as examples.
A young male presents to the emergency department (ED) after sustaining a blow to the head. He is agitated and has a Glasgow Coma Scale of 7. Based on your concern for rapid decompensation, you decide to perform rapid sequence intubation. He is otherwise a young and healthy, thin male so you are not too concerned that this will be a difficult airway. Except it is. Your heart starts to race as you are bagging the patient and wonder what to do next…
You are in the middle of a busy ED shift and continue to get interrupted time and time again. Once you think you can sit down for a second to type your first note, the nurse interrupts you with yet another request. You can feel your blood start to boil…
STRATEGIC STRESSOR SOLUTIONS
Both of these hypothetical cases deal with moment to moment stressors of a shift. These stressors may entail making difficult decisions, dealing with frequent interruptions and managing complicated patients. The stressors may even worsen at end of shifts and/or as one becomes frustrated, hungry and/or fatigued. In these situations, informal mindfulness practices may be useful.
For instance, during a stressful moment such as Case 1, the emergency physician may become extremely anxious about the difficult airway. Rather than focusing on his or her anxiety, taking a few deep breaths to get back to the situation can be helpful. Of course, this does not mean leaving the room or abandoning one’s focus on the situation at hand. Rather, the deep breaths may help keep one centered so that attention can be brought back to the moment. It may allow one to prevent their mind from wandering toward the outcome and/or the reasons behind why the situation occurred. Accepting a circumstance allows one to regain focus on moment to moment solutions.(12, 13)
The informal method of mindfulness may also be useful to help with unwanted thoughts or emotions that certainly most emergency physicians encounter on shifts. These may include emotions such as anger, irritability, grumpiness and fear.
In Case 2, the frequent interruptions may bring out some of these unwanted emotions. However, these irritations may allow us to be mindful of how many times during a shift (or a day, really) we have unwanted thoughts and emotions. These occasions may allow us to truly think about how much our well-being depends upon having things our way.(12) Being mindful of these unwanted emotions can also be therapeutic because it (a) makes us realize our thoughts and (b) allows us to realize that we do have choices in these moments.
These moments remind us to try to see situations more clearly when they arise in the future.(12) If one wants to improve upon an informal practice of mindfulness, there are apps and other resources that can help remind one to remain mindful during the day. One of these is Mindfulness Daily. Available on both iTunes® and Google Play™, this app provides pop-up reminders during the day that may help the emergency physician to be mindful. This includes a morning intention and daily lesson, a short pause during the day and a mindful reflection at night.(21) Signing up for the service is free, but a subscription is necessary to use the entire product.
Case 3 is another likely familiar case scenario: Your shift is finally over and you head home. However, once you get home, your spouse requests dinner. Your notice the house is a mess, there is a pile of laundry to do and the dog has yet to go for his walk. You are exhausted, overwhelmed and you wonder if the daily monotony will ever end…
This is an example of the work-life balance that can be so difficult for many. Having multiple stressors can ultimately lead to burnout, anxiety and/or depression.(22) The good news is that, over time, mindfulness may relieve stress and reduce symptoms of depression and anxiety.(15) Just a few weeks of engaging in meditation can be beneficial. For the overwhelmed emergency physician, using both informal and formal techniques, can improve quality of life, reduce stress levels and prevent burnout.(10, 15)
Starting a formal meditation program does not have to be difficult. For the physician who wants to start a regular meditation program for improving symptoms of depression, anxiety or even burnout, an app called Insight timer may be useful. It is rated as the top free meditation app on both iTunes ® and Google Play ™. With a total of 7,954 free guided daily meditations, the community connects with 1,692 meditation teachers in 25 languages.(23)
Finally, one excellent book to start reading is “Mindfulness for Beginners” by Dr. Jon Kabat-Zinn. It provides short chapters of useful information that one can read intermittently to help develop a mindfulness practice.(12) Over time, regular meditation may lead to an improved outlook and decrease the chances of burnout. Additionally, it may also improve depression and/or anxiety and help the emergency physician cope with the daily stressors of life.
CONCLUSIONS
We all have stresses and difficulties, both personally and professionally. While there are many ways of coping, mindfulness has been found to be a potential way for many to reduce anxiety, relieve depression and focus on the important tasks at hand. Mindfulness meditation has even been found to positively alter brain function.(15)
While committing to a mindfulness program may be a challenge, only a few minutes per day may be useful. While professional groups, hospitals and government officials work on policies to prevent burnout, perhaps mindfulness, on an individual level, can be helpful. If you are teetering on the edge of burnout and nothing has seemed to work yet, give mindfulness a try. It may be just what the doctor ordered!
REFERENCES
1. Cohen JK. Medical group publishes 8-step charter to address physician burnout [Internet]. 2018 [cited April 8, 2018]. Available from: https://www.beckershospitalreview.com/hospital-physician-relationships/medical-group-publishes-8-step-charter-to-address-physician-burnout.html
2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90 (12): 1600-1613.
3. Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: A review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract 2009; 15(2):61-6.
4. Miller NM, McGowen RK. The painful truth: physicians are not invincible. South Med J 2000 93(10):966-73.
5. Wolff GE, Crosby RD, Roberts JA, et al. Differences in daily stress, mood, coping, and eating behavior in binge eating and nonbinge eating college women. Addict Behav 2000; 25(2):205-16.
6. Sinha R. How does stress increase risk of drug abuse and relapse? Psychopharmacology 2001; 158(4):343-59.
7. Holahan CJ, Moos RH, Holahan CK, et al. Drinking to cope, emotional distress and alcohol use and abuse: a ten-year model. J Stud Alcohol 2001 Mar; 62(2):190-8.
8. Brown KW, Ryan RM, Creswell JD. Mindfulness: Theoretical Foundations and Evidence for its Salutary Effects. Psychol Inq 2007; 18(4):211-37.
9. Kabat‐Zinn J. Mindfulness‐Based Interventions in Context: Past, Present, and Future. Clinical psychology: Science and practice 2003; 10(2):144-56.
10. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry Med 2012; 43(2):119-28.
11.Kuyken W, Byford S, Taylor RS, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J Consult Clin Psychol 2008; 76(6):966.
12. Kabat-Zinn J. Mindfulness for Beginners. Jaico Publishing House; 2006. Print.
13. Bishop SR, Lau M, Shapiro S, et al. Mindfulness: A proposed operational definition. Clinical psychology: Science and practice 2004; 11(3):230-41.
14. Shapiro SL, Oman D, Thoresen CE., et al. Cultivating mindfulness: effects on well‐being. J Clin Psychol 2008; 64(7):840-62.
15. Greeson JM. Mindfulness research update: 2008. Complement Health Pract Rev 2009; 14(1):10-18.
16. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003; 65(4):564-70.
17. Kilpatrick LA, Suyenobu BY, Smith SR, et al. Impact of mindfulness-based stress reduction training on intrinsic brain connectivity. Neuroimage 2011; 56(1):290-8.
18. Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res Neuroimaging 2011; 191(1):36-43.
19. Pickut BA, Van Hecke W, Kerckhofs E, et al. Mindfulness based intervention in Parkinson’s disease leads to structural brain changes on MRI: a randomized controlled longitudinal trial. Clin Neurol Neurosurg 2013; 115(12):2419-25.
20. Singleton O, Holzel BK, Vangel M., et al. Change in brainstem gray matter concentration following a mindfulness-based intervention is correlated with improvement in psychological well-being. Front Hum Neurosci 2014; 8:33.
21. Mindfulness Daily. 2018 [March 29, 2018]. Available from: http://www.
22. Iacovides A, Fountoulakis KN, Kaprinis S, et al. The relationship between job stress, burnout and clinical depression. J Affect Disord 2003; 75(3):209-21.
23. Insight Timer [Internet]. 2018 [March 29, 2018]. Available from: https://insighttimer.com
3 Comments
Editor:
Don’t publish if you feel the column’s author regards what I say as personal.
tom
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I write to express concern about all we’re hearing about burnout prevention , here by convenient example, mindfulness and other strategies.
If I never attend another resilience talk, I’m have recovered a few hours and be a happy person.
My concerns run thusly:
Why is the burnout there?
I get it; taking care of yourself is important. We know to change the oil in our cars and to buy a good bed. oh, and go easy on the gin, even in malaria-prone areas. Exercise, diet and proper rest are important to everyone, whether on a burnout path or in a totally chill lifestyle.
So why is burnout an issue? A better question would be: What causes burnout, why is it present?
A simplified answer: it’s the environment.
I think, as EM physicians, we are uniquely poised to present the answer: change the environment!
I think this is becoming an ethical imperative. We know the system is toxic, broken, hurting our young, bright kids we send into it.
We tell them: “Buck up; be resilient. Take what’s being thrown at you. Don’t be a weenie.” “We know the Electronic Billing System doesn’t support what you’re sent to do; we won’t fix it, but we’ll supply you with scribes and we’ll call it a Medical Record.”
The dissonance of the messages is striking.
Of course, take care of yourself!
And mindfulness is, for sure, a practice to take the beside, being fully present to your patients. You’ll do a better job, the patients will like you better, your likelihood of a lawsuit goes down, etc.
But let’s change the system instead of presenting our youngest, best and brightest to the jaws of the machine, giving them a pat on the back and a “You go, Girl!”
To paraphrase Surowiecki (New Yorker), it is all well and good to confess our sins, but it is better that we stop committing them.
Yes, of course it’s the environment. Our environment is stressful. New flash: life is stressful. But here is the secret to the success of mindfulness practice: it changes OUR PERSPECTIVE of the environment, and hence, it changes OUR reality. In the end, that’s all that really matters.
Thank you Jen for this article. I really enjoyed reading it and it stirs up a lot of thoughts and emotions. Burnout is not a problem of personal resilience, it is a problem born out of the structure of the organizations within which we work, and the endemic problems of our national healthcare system. Mindfulness is a powerful tool for helping us as individual EPs, I know because I practice it and it helps me immeasurably on shift to meet the challenges this all consuming job presents me with. That said, if an administrator comes to be and presents mindfulness training as a systems level response to the ills of the system, I would tell them to go screw themselves and give me a humane schedule and a supportive organizational structure, a working EMR and good ancillary staff. We should kept the power of mindfulness to ourselves as working EPs, use it as much as possible as individual EPs and never allow the system to abdicate its responsibility to institute organizational change just because they offer an individual-level strategy like mindfulness to workers. It is a fine balance, because mindfulness really really works to help individuals, it should just not be the first response of administrators who don’t practice it, and who are looking for a way to quell dissent because it is easier for them than introducing real systemic change that costs them actual money. I teach residents how to use mindful attention on shift because I know it will help them turn tasks that drain us into experiences that feed us, but I also remind them that the systems that burn them out need change, and that change is practical, real world stuff that they should never stop agitating for. A mindful EP physician is mindful of more than just the moment to moment reality that supports attention and compassion, they are mindful of the context they work it, and the systemic problems that need their attention to change. Thank you again Jen for the article, it was well written and I am grateful for you and your attention to this topic.