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In dealing with other people, we must not only be aware of what they are saying, but we must also be open to the whole tone of their being. A person’s actual words and smile represent only a small fraction of their communication. What is equally important is the quality of presence, the way he or she presents themselves to us. This communicates much more than words alone.

from “Prajna and Compassion” in Cutting Through Spiritual Materialism by Chögyam Trungpa, page 246

Who Will Heal the Doctors?

In my previous column, I reported on the problem of widespread burnout among doctors and medical students — and I described a response that, in recent years, has spread to half the nation’s medical schools: a course called The Healer’s Art, created by a physician, Rachel Naomi Remen, to help doctors and students discover and reconnect to the deep meaning of their work and maintain their commitment for it. The article touched a sore spot. Hundreds of readers — patients, medical students, doctors and spouses and children of doctors among them — contributed comments describing their personal experiences, many of them raw with emotion. Some of the most poignant notes came from doctors themselves, and their words revealed a deep sense of betrayal.

The ability to derive meaning from our work can transform our daily experiences.

“I am a primary care doctor who started idealistic, and am disillusioned and dejected,” wrote one reader from New York City: “By far, the biggest barrier to being a compassionate healer in our current working environment is time. We simply don’t have the time we need to do our jobs well. And we all lose.”

The husband of a doctor from Huntington, Pa., wrote that his wife, who worked 70 to 110 hours a week, was “constantly chafing against the demands for ‘productivity,’ the necessity to spend hours fighting insurers to get treatment for her patients and the fatigue that results from hours of work doing electronic ‘paperwork’ long after the patients have been seen.”

“Yes, changing the culture of physician training is important,” he added. “But we also need to turn back the disastrous process of the McDonaldization of healthcare.”

The toll begins early. Holly, a fourth-year medical student, from Maryland, wrote: “I am emotionally exhausted and suffering from burnout. I realize how scared and vulnerable my patients must be feeling. Unfortunately, I am unable to spend the time I’d like with each patient because I have so many other patients whose needs must also be met.”

In my reporting on The Healer’s Art, I interviewed numerous medical students and doctors, who reported that the course provided them with a unique opportunity to talk about their personal and family experiences as patients, doctors, or doctors in training, and to share their fears, joys, rewards and struggles. They said the course allowed them to reflect on these experiences alongside peers and teachers in a safe setting that was unavailable elsewhere in the medical curriculum. Many added that the experience enabled them to maintain their spirits and their sense of “wholeness” during their training, and, later, dealing with a dysfunctional health system that seemed designed to “beat the humanity” out of them.

“The reasons people go into medicine are often woven deeply into who they are,” explains Remen, who has taught The Healer’s Art at the University of California—San Francisco for more than 20 years. “Despite difficult and sometimes impossible demands placed on them, they will continue to try to do their best to care for people, but the system always asks them to function far below their level of personal excellence. When you compromise your best self on a daily basis, something gets extinguished in you — and that something is what has kept the profession of medicine alive for thousands of years.”

The Healer’s Art doesn’t purport to fix the health care system. “It’s about how to help the people in medicine survive the system,” adds Remen.

People who are caught in oppressive systems adopt various stances toward them, consciously or unconsciously. They may choose to abandon the systems; today many doctors are doing just that. Several wrote in to say that they had already quit medicine, or were planning to quit soon. “I retired early from medicine, was glad to get out, and don’t regret fleeing a broken system,” wrote J. Skinner from the Midwest.

Others remain in the system, but they build walls of protection, growing cynical or detached. They experience low satisfaction with their work, become depressed or abuse drugs. Suicidal ideation is significantly more common among surgeons than among the general population, for example.

But there is a third way: the ability to derive meaning from our work can transform our daily experiences. Doctors may be individually powerless to change the system, but they do have tools to rediscover and strengthen their capacity to practice wholeheartedly. One such method is to cultivate “mindfulness” — the ability to be present in a nonjudgmental way. Not only do improvements in mindfulness appear to improve doctors’ sense of well-being, they seem to improve their patient-centeredness, as well — something known to be associated with better, safer and more satisfying care, explains Michael S. Krasner, an Associate Professor of Clinical Medicine at the University of Rochester School of Medicine and Dentistry, who has co-written a study on the topic.

The Healer’s Art teaches mindfulness and also helps medical students explore meaning through exercises in which they share their personal experiences in patient care and reflect on their sense of calling and the effect of compassion at times of loss. In my previous column, I mentioned some instances where doctors expressed their caring directly to patients — even crying silently alongside them — and a number of readers raised a red flag.

Individual doctors have the tools to rediscover and strengthen their capacity to practice wholeheartedly.

“Most of us do not want a doctor who is caring and concerned,” wrote Tim Kirn, the son of a doctor from Sacramento. “We want a doctor who is competent. It seems highly unlikely that someone who is emotionally invested, and therefore stressed, is going to function better than someone who is cold.”

This is a common misconception. As I reported, being emotionally attuned can help a doctor, or anyone for that matter, function better. Indeed, the notion that a doctor is an objective, Spock-like, scientist whose job is to come up with the one best solution to your problem is a view that is out of step with research on medical outcomes and much of what is known about the therapeutic aspects of the patient-doctor relationship. People are not widgets; medicine cannot be reduced to cutting and sewing or putting chemicals into the body; it’s full of mystery. Doctors can often make a difference in how patients feel simply by being caring and concerned.

Consider a study that examined the effects of placebos on patients suffering from irritable bowel syndrome — a chronic gastrointestinal disorder that causes constipation and pain. Researchers separated patients into three groups: the first received no treatment, the second received a placebo — fake acupuncture (using a retractable needle); the third received the same placebo, but administered by a practitioner who was highly caring, empathetic and confident. The proportion of patients reporting relief were 28 percent, 44 percent and 62 percent, respectively.

Placebos frequently elicit subjective improvements among patients, possibly by triggering a release of dopamine in the brain. What was unusual about the study was that the relational context influenced the response. Now consider that some 100 million Americans suffer from chronic pain. Many become addicted to painkillers. Could more caring doctors bring therapeutic benefits to some of them?
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What about the therapeutic benefits that patients could confer on doctors? More and more people are living with incurable diseases that would have killed them a short time ago. As the population ages, more health care will be directed to patients with chronic or terminal conditions. For doctors, care will become less a question of curing a disease than helping their patients to live as well as possible in the face of their illnesses. That’s not the job they train you for in medical school. But in this emerging context, the doctor patient relationship becomes even more central. It may be the quality of this relationship that determines whether doctors can cope with, and derive satisfaction, from care that involves far less clinical certainty or control.

Over all, readers were not optimistic about the prospects for reforming medicine, but some of those who did see potential for change placed the main responsibility with the doctors themselves. “A lovely and touching article,” wrote Steven Frucht a reader from New York City. “Unfortunately it won’t change anything in the real world. Why? Because physicians do not control the way medicine is practiced.”

He added: “Physicians must stand up, specialty by specialty, and refuse to accept this ridiculous system that rewards electronic care, rather than patient care.”

Another, Les from Bethesda, Md., wrote, “What we — the doctors and the patients — have to decide is what we want medicine to be. If we want it to be an artful profession that deftly merges compassion and science we can do that … But as some of have noted, we have to stand up and demand this.”

The idea that doctors might find the inner strength to voice their deepest beliefs is in keeping with the focus of Remen’s work.

“The greatest of all stresses does not come from a lack of sleep or time,” she observes. “It comes from believing deeply in one set of values and finding that you are trapped into living by another set.”

In The Healer’s Art, she says, she envisions “enabling people to recognize the gap between doctors’ professional service values and the values of the health system, so that it becomes more possible for doctors to speak out on behalf of patients, and rise up as a community and simply say, ‘You know, when people are in pain and facing something unknown and potentially life altering, being told that you have seven minutes to understand their unique issues and strengths in order to find effective ways to help them is just wrong. It is simply unethical — and I am not doing this anymore.”

Could physicians come together to overthrow the current order — to start a movement to, say, Occupy Medicine? If they did, what would be the unifying cry? Down with health insurers? Tort reform or bust? Or would it begin by expressing the thing that is most precious to them that has been lost: the opportunity to practice medicine in a way that is worthy of their dedication and love. Reclaiming a sense of meaning in medicine could be the first step to rescuing the profession.

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David Bornstein

David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.

Every day, we are reminded that the health care system is in crisis. We are going bankrupt. There are too many lawsuits. We practice defensive medicine. We restrict access. But surveys of doctors indicate a problem that penetrates much deeper than this. Today, almost 50 percent of doctors report symptoms of burnout — emotional exhaustion, low sense of accomplishment, detachment.

Countering doctor burnout with a refresher course on the capacity to heal.

Medicine is facing a crisis, but it’s not just about money; it’s about meaning.

We often think of medicine as a science, and many doctors do come to think of themselves as technicians. But healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery. I was often moved by how much my father-in-law — an actor who died from a form of leukemia — drew comfort and even inspiration from the relationship he had with his hematologist (who requested a Shakespeare recitation at each visit).

Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Declaration of Geneva (“I solemnly pledge to consecrate my life to the service of humanity…”) or the Oath of Maimonides (“May I see in all who suffer only the fellow human being.”)

Yet by then, considerable damage has already been done. Nearly half of medical students become burned out during their training. Medical education has been characterized as an abusive and neglectful family system. It places unrealistic expectations on students, keeps them sleep-deprived, overstressed, and in a state of fear of making mistakes, and sends the message that doubts or grief should be kept to oneself. While the training formally espouses the ethics of empathy, compassion and altruism, doctors and researchers say that the socialization process — the “hidden curriculum” — teaches something very different: stay detached, objective, even a little cynical. Five out of six doctors say that medicine is in decline and close to 60 percent would not recommend it as a career for their children (pdf).

As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship.

“These high levels of distress, depression, loss of satisfaction, fatigue, and burnout have big repercussions for quality of care,” explains Dr. Tait Shanafelt, director of the Mayo Clinic Department of Medicine’s program on physician well-being. It leads to medical errors, substance abuse, and doctors quitting — something that a country with an aging population and a shortage of doctors can ill afford.

How could we help medicine overcome its own illness?

That’s a question that has occupied Dr. Rachel Naomi Remen for decades. Remen is a clinical professor of family and community medicine at the U.C.S.F. School of Medicine and the director of the Institute for the Study of Health and Wellness, at Commonweal. Over the past 22 years, she has been advancing a powerfully subversive addition to the medical curriculum, a course called The Healer’s Art.
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For the first six years, Remen taught it with 10 friends, all community physicians drawn from outside the school. She was half afraid that her dean would discover it and throw her out. But gradually, the course began to spread by word of mouth, to two schools, then four, then 16, then 25. It is now taught annually at 71 schools in the United States (half of the nation’s medical schools) and schools in seven other countries.

More than 1,600 students take the course each year and about 13,000 have gone through it. And while it is described as a simple elective — a 15-hour course given in five three-hour sessions — many of the doctors who teach it, and the students who take it, see it as part of a movement. In evaluations, large majorities of students say the course fills a gap in their medical education. It helps them to feel more committed to medicine, more supportive of their classmates, more confident that they can be good doctors, and more clear about what they can personally offer patients. More than 95 percent of them say they will recommend it to other students.

“What our students say loud and clear is this course helps to keep their spirits alive as they go through the training,” explains Nancy Oriol, dean for students at Harvard Medical School.

Remen’s life has been shaped by her own experience living with illness. By her own admission, she has not been well for 60 years. When she was 15, she was diagnosed with Crohn’s disease. She underwent nine major surgeries and took large doses of steroids daily for 15 years. “My doctors told me I would be dead by the time I was 40,” she says with a laugh. She’s now 75 and has been a doctor herself for 50 years.

After medical school, on her first day in training as an intern, a 3-year-old was brought into the emergency room after a car accident. The doctors were unable to save the child’s life. Remen accompanied the chief resident as he met with the parents to inform them that their child had died. When they broke down, the sadness was too much. Remen found herself crying, too.

Afterward, the chief resident took Remen aside and said that her behavior had been highly unprofessional.

The message stuck. By the time Remen was senior resident, she hadn’t cried for years. That year, another child, a baby, was brought into the hospital after drowning unattended in his bathtub. The doctors were unable to resuscitate the baby. This time, Remen was the one responsible for informing the parents that their only child had died — and as they held each other and fell apart sobbing — she stood silently by in her white coat, maintaining her professional distance. After a while, the baby’s father, with tears running down his face, apologized. “‘I’m sorry, doctor,’ he said. ‘I’ll get a hold of myself in a minute.’”

How had she become the person a grieving father apologizes to? This is a common outcome of the hidden curriculum.

Medicine’s ‘hidden curriculum’ teaches that doubts and grief are forbidden.

The Healer’s Art is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students and doctors connect to these values in a community, they derive meaning and strength, and can “immunize” themselves against the assaults of the medical curriculum and even the health care system itself.

To help people tap into these deep currents, the course is delivered in an unusual manner. Students and faculty members meet together in small groups in the evenings, participating side by side as equals. There are no experts, no hierarchies, no wrong answers; anyone may speak about his or her experiences or simply listen.

It begins by reminding people that it is not by chance that they are in the room. “We ask: ‘How old were you when you first realized that the needs of a living thing mattered to you?’” says Remen. “For most doctors and students, the impulse to respond to the needs of others, plants, animals, insects, and even people, goes back to early childhood, sometimes as far back as they can remember.”

Remen recalled a student who told the class that his mother used to bathe him in an old claw-footed bathtub. “At the end of his bath, she would pull out the stopper, reach behind him and get a towel, sit him on her lap and dry him. One day he stepped on the drain and it was sharp — there was pain and blood — and his mother said, ‘Never stand on the drain again.’ A few weeks or months later, as he was waiting for her to dry him, he noticed the water circling the drain as the tub emptied. He remembered how sharp the drain was and worried that the water was being hurt. After that, when his mother pulled the plug, he would drop his washcloth over the drain to protect the water.

“This is magical thinking. He was probably about 3,” said Remen. “Now he is a pediatrician and he brings the same intention to make a difference in pain and suffering to his little patients himself.”

Every culture approves and disapproves of different qualities. As the price of admission, medicine implicitly asks its members to leave aspects of themselves behind. The course explores this idea, what Carl Jung called the “shadow.”

“Everybody’s given a box of crayons and a big piece of paper like in first grade and they are asked to draw a picture of the parts of themselves they feel they can’t bring into their work as doctors,” explains Joseph O’Donnell, a Senior Advising Dean at the Geisel School of Medicine at Dartmouth, who has taught the course for more than a decade. First-year students do the exercise alongside doctors who have been practicing for decades. “Then everyone holds up their picture. You see ‘curiosity,’ ‘love,’ ‘compassion,’ ‘kindness,’ ‘creativity.’ And people say, ‘I thought I was the only one experiencing this.’ ”

The session on grief and loss is among the most powerful, adds O’Donnell. “Students and faculty are asked to become still and quiet,” he explained. “They’re asked to think back to a time when they experienced a loss, and remember the feelings, and think about what someone may have done that was helpful, or unhelpful.”

They write it down. Then the students are asked to say what was helpful. “You hear things like: They held my hand. Gave me a hug. Brought me food. Sat silently and listened.” For unhelpful, you hear things like, “They said, ‘I’d better leave you alone” or “You’ll be fine in no time.’”

When O’Donnell graduated from medical school in 1973, there was no place to discuss such matters openly. “It wasn’t safe to say, ‘I’m really bothered by what I’m seeing today.’ You just took care of it. You read the scientific articles, but you put your heart and soul aside. Here you are allowed to bring those things to the forefront in a valid way with colleagues who are esteemed.”

Dean Parmelee, the Associate Dean for Academic Affairs at Wright State University, who has taught the course for several years, recalled an incident shared by a fourth-year student who had been part of a team when a baby was stillborn.

The mother was 16 or 17 years old and she was with her boyfriend, he recalled. There were some psychosocial issues. “After the delivery, the student said, shockingly, everyone just left the operating room,” said Parmelee. “He was the only person left and the only sound was the air-conditioning and the ventilation.” The mom had started to cry; her baby lay still on her abdomen. The boyfriend was crying, too. The student said nothing. He simply reached out and took the mother’s hand and with his other hand he reached out and took the father’s hand, closed his eyes and stood there with them for a few minutes crying silently together.

“The student said that if he hadn’t taken the course, he would have left the room like everyone else,” added Parmelee. “Or he might have said something like, ‘You’re young, you can have another baby.’ ”

“Instead,” commented Remen, reflecting on the story, “he offered them and himself the healing of a common humanity.”

‘I saw that you don’t have to become hardened,’ a medical student said.

This is not how doctors are accustomed to managing grief and loss. “We intellectualize it, minimize it, become numb to it,” O’Donnell said.

There is an enduring belief in medicine that if you feel strongly it will cloud your judgment. But research indicates that emotional attunement can improve critical thinking, decision-making, and the ability to act quickly in crisis moments.

Moreover, we need to feel to connect with other human beings. “If patients see that you care, they can trust you enough to tell you the truth and are more likely to follow your advice,” observes Remen. Parmelee, who has been an expert witness in malpractice cases, has found that most cases boil down to physicians “not really listening or making themselves available emotionally for a patient.”

And then there is the simple truth that buried feelings don’t just go away. “When I took The Healer’s Art, the session on grief and loss brought up a whole period in my life that I must have tried hard to not think about,” recalled Parmelee. “I was totally unaware of its continuous impact on me, and how much was still there after more than 30 years.”

In medical school, students rarely hear their teachers speak this way. Brent Aebi, a third-year medical student at Wright State University, said that hearing veteran doctors speak about their struggles helped him to see a path forward that felt right to him. “I saw that you don’t have to become hardened,” he said.

The same holds for peers. The combination of hyper-competition and self-doubt in medical school can work against the development of supportive relationships. “This way of listening to others’ stories is not present in the normal medical training,” observes Rhianon Liu, a third-year medical student at Johns Hopkins School of Medicine. “And it showed me that the most important protective mechanisms are the relationships we build with our classmates and faculty.”

Indeed, the importance of listening comes across as one of the course’s biggest lessons. “Students comment that they never realized how powerful silence is in communication,” said Parmelee.

For O’Donnell, who oversees oncology at the Veterans Administration Hospital in White River Junction, Vt., the course has helped him learn to listen more deeply. “I hear themes I might have missed before,” he says. “Not just the symptoms, but the story — how scared the patient is that this ache might mean a recurrence. It brings you back to taking care of people. Because the world isn’t made up of atoms. It’s made up of stories.”

The Healer’s Art is an entry point: an attempt to anchor a cultural shift in medicine. Some students who have taken the course have formed groups so they can continue to uncover the meaning of their work after the course ends. They are building an alternative socialization process. The Institute for the Study of Health and Illness also helps doctors, nurses and other health care professionals form groups dedicated to “Finding Meaning in Medicine.”

But the course and similar programs need to be given much higher priority if we are going to attack burnout. “Because it has strong links to the quality of care,” says Dr. Shanafelt of the Mayo Clinic, “promoting wellness is a shared responsibility of individual physicians as well as the hospital or practice group.”

However, if hospital administrators are going to allow doctors to cut back on “productive” activities so they can take time to focus on self-care, he adds, “We’ll need to provide hard evidence for people making financial decisions that this is a good investment.”

For doctors, this investment could mean the difference between succumbing to burnout and finding ways to practice that deepen their sense of purpose. “When doctors learn to read the affective domain, they are shocked to discover that they have gone right past experiences of profound meaning without seeing them,” says Remen. “They say, ‘I was colorblind.’ Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.”

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David Bornstein

David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.

According to the nurse’s note, the patient had received a clean bill of health from his regular doctor only a few days before, so I was surprised to see his request for a second opinion. He stared intently at my name badge as I walked into the room, then nodded his head at each syllable of my name as I introduced myself.

Shifting his gaze upward to my face, he said, “I’m here, Doc, to make sure I don’t have anything serious. I’m not sure my regular doctor was listening to everything I was trying to tell him.”

I smiled. To hide my embarrassment.

I had walked into the exam room to listen to this patient; but my mind was a few steps behind, as I struggled with thoughts about the colleague who’d just snapped at me over the phone because she was in no mood to get another new consult, my mounting piles of unfinished paperwork, and the young patient with widespread cancer whom I’d seen earlier in the day. Thoughts about my new patient jumbled in the mix, too, but they came into focus only after I had pushed away the fears that I might have neglected to order a key test on my last patient, that I’d forgotten to call another patient and that I was already running behind schedule.

That relentless inner conversation came to mind this past week when I read two studies on physician burnout and mindfulness in the current issue of The Annals of Family Medicine.

Research over the last few years has revealed that unrelenting job pressures cause two-thirds of fully trained doctors to experience the emotional, mental and physical exhaustion characteristic of burnout. Health care workers who are burned out are at higher risk for substance abuse, lying, cheating and even suicide. They tend to make more errors and lose their sense of empathy for others. And they are more prone to leave clinical practice.

Unfortunately, relatively little is known about treating burnout. But promising research points to mindfulness, the ability to be fully present and attentive in the moment, as a possible remedy. A few small studies indicate that mindfulness training courses can help doctors become more focused, more empathetic and less emotionally exhausted.

But two important questions remain unanswered. How does mindfulness affect patients? And who really has the time to enroll in training courses that can take several weeks or longer?

The studies in The Annals of Family Medicine attempt to answer those questions.

In one study, researchers first assessed the baseline mindfulness of 45 doctors, nurses and physician assistants by asking them to respond to statements like, “I tend to walk quickly to where I am going without paying attention to what I experience along the way,” “I find myself listening to someone with one ear, doing something else at the same time,” and “I forget a person’s name almost as soon as I’ve been told it for the first time.” Then the investigators recorded the clinicians’ interactions with more than 400 patients and interviewed the patients to gauge their level of satisfaction.

After analyzing the audio recordings and the patients’ responses, the researchers found that patients were more satisfied and more open with the more mindful clinicians. They also discovered that more mindful clinicians tended to be more upbeat during patient interactions, more focused on the conversation and more likely to make attempts to strengthen the relationship or ferret out details of the patient’s feelings.

The less mindful clinicians, on the other hand, more frequently missed opportunities to be empathic and, in the most extreme cases, failed to pay attention at all, responding, for example, to a patient’s description of waking up in the middle of the night crying in pain with a question about a flu shot.

Significantly, the most mindful doctors remained efficient. They accomplished just as much medically for their patients as their least mindful colleagues, despite all the extra conversation with patients about experiences and relationships.

“We clinicians are not always fully present for patients because our minds are always working,” said Dr. Mary Catherine Beach, lead author of the study and an associate professor of medicine at Johns Hopkins University. “But when we don’t listen,” failing to let patients say what they need to say or ask what they need to ask, “we end up giving explanations that are too long and complicated and responses that they don’t need or want.”

For many doctors, it’s not the lack of interest that prevents them from incorporating mindfulness into their clinical practices; it’s the time required to complete a standard training course. The courses require a significant commitment, ranging from a full week, to a full day once a week for eight weeks.

In the second study, another group of investigators looked at the effects on 30 physicians of a mindfulness course that required only one weekend and two follow-up evening sessions a couple of weeks apart. Even after such an abbreviated course, the researchers found decreased levels of burnout, anxiety, depression and distress among the doctors. And nearly a year later, those salutary effects persisted, even without any mindfulness training “booster” sessions.

“We tried to get the training down to the bare minimum and as user-friendly as possible,” said Dr. Luke Fortney, lead author of the study and an integrative and family medicine physician who is part of the Meriter Medical Group at the McKee Clinic in Madison, Wis. “We didn’t want to exhaust the doctors with another burden.”

Dr. Fortney and his colleagues filled the condensed course with techniques adapted for busy clinicians, like the “two feet one breath” technique in which a doctor, just before entering an exam room, stands in front of the door and concentrates on breathing and the feeling of his or her feet on the ground as a way to help focus on the moment. They also created a practical and accessible Web site that reinforces key points and offers helpful advice in the form of short videos, brief audio recordings and easy-to-digest tables.

While more work needs to be done, these two studies add to the growing body of research supporting mindfulness training as a way to improve the health of both doctors and their patients. “Mindfulness gives doctors permission to attend to their own health and well-being,” Dr. Beach said. “But it also allows doctor to help patients by listening more, talking less, and seeing what the patients need.”

 

By PAULINE W. CHEN, M.D., NYT

Background Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields.

Methods We conducted a national study of burnout in a large sample of US physicians from all specialty disciplines using the American Medical Association Physician Masterfile and surveyed a probability-based sample of the general US population for comparison. Burnout was measured using validated instruments. Satisfaction with work-life balance was explored.

Results Of 27 276 physicians who received an invitation to participate, 7288 (26.7%) completed surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians reported at least 1 symptom of burnout. Substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine). Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both). Highest level of education completed also related to burnout in a pooled multivariate analysis adjusted for age, sex, relationship status, and hours worked per week. Compared with high school graduates, individuals with an MD or DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P < .001), whereas individuals with a bachelor’s degree (OR, 0.80; P = .048), master’s degree (OR, 0.71; P = .01), or professional or doctoral degree other than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.

Conclusions Burnout is more common among physicians than among other US workers. Physicians in specialties at the front line of care access seem to be at greatest risk.

Although the practice of medicine can be incredibly meaningful and personally fulfilling, it is also demanding and stressful. Results of studies1- 3 suggest that many physicians experience professional burnout, a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. Although difficult to fully measure and quantify, findings of recent studies4- 8 suggest that burnout may erode professionalism, influence quality of care, increase the risk for medical errors, and promote early retirement. Burnout also seems to have adverse personal consequences for physicians, including contributions to broken relationships, problematic alcohol use, and suicidal ideation.9- 11

Despite the extensive data on physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians. Although there has been much conjecture about which medical or surgical specialty areas are high risk, this speculation has primarily been based on comparisons across studies of physicians from individual disciplines, for which differences in sample selection, study size and setting, participation rates, and year of survey administration confound interpretation. The literature on physician burnout is also hampered by a lack of data about how rates of burnout for US physicians compare with rates for US workers in other fields.

To address these issues, we conducted a national study of burnout among a large sample of US physicians in June 2011 that included representation across all the specialty disciplines. We also surveyed a probability-based sample of the general US population for comparison with physicians.

-Tait D. Shanafelt, MD; Sonja Boone, MD; Litjen Tan, PhD; Lotte N. Dyrbye, MD, MHPE; Wayne Sotile, PhD; Daniel Satele, BS; Colin P. West, MD, PhD; Jeff Sloan, PhD; Michael R. Oreskovich, MD; JAMA

BECOME THE PANIC

Usually when panic arises, we try to brush it off and occupy ourselves with something else. There is somebody very reasonable in us, who says, “This is your imagination. Everything is going to be okay. Don’t worry. Take a rest. Have a glass of milk.” But if instead you go along with the panic and become the panic, there is a lot of room in the panic, because the panic is full of air bubbles, so to speak. It is very spacious. You probably find yourself suspended in the midst of panic, which is suspended in space.

from Chogyam Trungpa Rinpoche’s “Orderly Chaos, The Mandala Principle.”

The Morality of Meditation

By DAVID DeSTENO
Published: July 5, 2013, NYT

MEDITATION is fast becoming a fashionable tool for improving your mind. With mounting scientific evidence that the practice can enhance creativity, memory and scores on standardized intelligence tests, interest in its practical benefits is growing. A number of “mindfulness” training programs, like that developed by the engineer Chade-Meng Tan at Google, and conferences like Wisdom 2.0 for business and tech leaders, promise attendees insight into how meditation can be used to augment individual performance, leadership and productivity.

This is all well and good, but if you stop to think about it, there’s a bit of a disconnect between the (perfectly commendable) pursuit of these benefits and the purpose for which meditation was originally intended. Gaining competitive advantage on exams and increasing creativity in business weren’t of the utmost concern to Buddha and other early meditation teachers. As Buddha himself said, “I teach one thing and one only: that is, suffering and the end of suffering.” For Buddha, as for many modern spiritual leaders, the goal of meditation was as simple as that. The heightened control of the mind that meditation offers was supposed to help its practitioners see the world in a new and more compassionate way, allowing them to break free from the categorizations (us/them, self/other) that commonly divide people from one another.

But does meditation work as promised? Is its originally intended effect — the reduction of suffering — empirically demonstrable?

To put the question to the test, my lab, led in this work by the psychologist Paul Condon, joined with the neuroscientist Gaëlle Desbordes and the Buddhist lama Willa Miller to conduct an experiment whose publication is forthcoming in the journal Psychological Science. We recruited 39 people from the Boston area who were willing to take part in an eight-week course on meditation (and who had never taken any such course before). We then randomly assigned 20 of them to take part in weekly meditation classes, which also required them to practice at home using guided recordings. The remaining 19 were told that they had been placed on a waiting list for a future course.

After the eight-week period of instruction, we invited the participants to the lab for an experiment that purported to examine their memory, attention and related cognitive abilities. But as you might anticipate, what actually interested us was whether those who had been meditating would exhibit greater compassion in the face of suffering. To find out, we staged a situation designed to test the participants’ behavior before they were aware that the experiment had begun.

WHEN a participant entered the waiting area for our lab, he (or she) found three chairs, two of which were already occupied. Naturally, he sat in the remaining chair. As he waited, a fourth person, using crutches and wearing a boot for a broken foot, entered the room and audibly sighed in pain as she leaned uncomfortably against a wall. The other two people in the room — who, like the woman on crutches, secretly worked for us — ignored the woman, thus confronting the participant with a moral quandary. Would he act compassionately, giving up his chair for her, or selfishly ignore her plight?

The results were striking. Although only 16 percent of the nonmeditators gave up their seats — an admittedly disheartening fact — the proportion rose to 50 percent among those who had meditated. This increase is impressive not solely because it occurred after only eight weeks of meditation, but also because it did so within the context of a situation known to inhibit considerate behavior: witnessing others ignoring a person in distress — what psychologists call the bystander effect — reduces the odds that any single individual will help. Nonetheless, the meditation increased the compassionate response threefold.

Although we don’t yet know why meditation has this effect, one of two explanations seems likely. The first rests on meditation’s documented ability to enhance attention, which might in turn increase the odds of noticing someone in pain (as opposed to being lost in one’s own thoughts). My favored explanation, though, derives from a different aspect of meditation: its ability to foster a view that all beings are interconnected. The psychologist Piercarlo Valdesolo and I have found that any marker of affiliation between two people, even something as subtle as tapping their hands together in synchrony, causes them to feel more compassion for each other when distressed. The increased compassion of meditators, then, might stem directly from meditation’s ability to dissolve the artificial social distinctions — ethnicity, religion, ideology and the like — that divide us.

Supporting this view, recent findings by the neuroscientists Helen Weng, Richard Davidson and colleagues confirm that even relatively brief training in meditative techniques can alter neural functioning in brain areas associated with empathic understanding of others’ distress — areas whose responsiveness is also modulated by a person’s degree of felt associations with others.

So take heart. The next time you meditate, know that you’re not just benefiting yourself, you’re also benefiting your neighbors, community members and as-yet-unknown strangers by increasing the odds that you’ll feel their pain when the time comes, and act to lessen it as well.

David DeSteno is a professor of psychology at Northeastern University, where he directs the Social Emotions Group. He is the author of the forthcoming book “The Truth About Trust: How It Determines Success in Life, Love, Learning, and More.”

ENJOYING THE CHAOS

Working with conflict is precisely the idea of walking on the spiritual path. The path is a wild, winding mountain road with all kinds of curves; there are wild animals, attacks by bandits, all kinds of situations cropping up. As far as the occupation of our mind is concerned, the chaos of the path is the fun.

-Chogyam Trungpa Rinpoche (The Dawn of Tantra)

Hey Seattle! Think of how lucky we are!

Br J Sports Med. 2013 Mar 6.
Aspinall P, Mavros P, Coyne R, Roe J.

School of Built Environment, Heriot-Watt University, Edinburgh, UK.

Researchers in environmental psychology, health studies and urban design are interested in the relationship between the environment, behaviour settings and emotions. In particular, happiness, or the presence of positive emotional mindsets, broadens an individual’s thought-action repertoire with positive benefits to physical and intellectual activities, and to social and psychological resources. This occurs through play, exploration or similar activities. In addition, a body of restorative literature focuses on the potential benefits to emotional recovery from stress offered by green space and ‘soft fascination’. However, access to the cortical correlates of emotional states of a person actively engaged within an environment has not been possible until recently. This study investigates the use of mobile electroencephalography (EEG) as a method to record and analyse the emotional experience of a group of walkers in three types of urban environment including a green space setting.
METHODS:

Using Emotiv EPOC, a low-cost mobile EEG recorder, participants took part in a 25 min walk through three different areas of Edinburgh. The areas (of approximately equal length) were labelled zone 1 (urban shopping street), zone 2 (path through green space) and zone 3 (street in a busy commercial district). The equipment provided continuous recordings from five channels, labelled excitement (short-term), frustration, engagement, long-term excitement (or arousal) and meditation.
RESULTS:

A new form of high-dimensional correlated component logistic regression analysis showed evidence of lower frustration, engagement and arousal, and higher meditation when moving into the green space zone; and higher engagement when moving out of it.
CONCLUSIONS:

Systematic differences in EEG recordings were found between three urban areas in line with restoration theory. This has implications for promoting urban green space as a mood-enhancing environment for walking or for other forms of physical or reflective activity.

Longevity of Thai physicians

Interesting article with relevance to US health care professionals interested in increasing their own (and their patients’) longevity …
J Med Assoc Thai. 2004 Oct;87 Suppl 4:S23-32.
 

Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

The objectives of this study were to explore characteristics of the long-lived Thai physicians. We sent 983 posted questionnaires to 840 male and 143 female physicians. We obtained 327 of them back after 2 rounds of mailing, yielding a response rate of 33.3 percents. The response rate of male physicians was 32.4 percents and that of female physicians was 38.5 percents. Their ages were between 68-93 years (75.1 +/- 4.86 years on average). The majority were married, implying that their spouses were also long-lived. Around half of them still did some clinical work, one-fourth did some charity work, one-fourth did various voluntary works, one-fifth did some business, one-fifth did some academic work, and some did more than one type of work. Most long-lived physicians were not obese, with BMI of 16.53-34.16 (average 23.97 +/- 2.80). Only 8 had BMI higher than 30. BMIs were not different between male and female physicians. However, four-fifths of them had diseases that required treatment, and some of them had more than one disease. The five most frequent diseases were hypertension, diabetes, ischemic heart disease, dyslipidemia, and benign prostate hypertrophy, respectively. Most long-lived physicians did exercise (87.8%), and some did more than one method. The most frequent one was walking (52.3%). Most did not drink alcohol or drank occasionally, only 9.0% drank regularly. Most of them slept 3-9 hours per night (average 6.75 +/- 1.06). Most (78.3%) took some medication regularly; of most were medicine for their diseases. Most did not eat macrobiotic food, vegetarian food, or fast food regularly. Most long-lived physicians practiced some religious activities by praying, paying respect to Buddha, giving food to monks, practicing meditation, and listening to monks’ teaching. They also used Buddhist practice and guidelines for their daily living and work, and also recommended these to their younger colleagues. Their recreational activities were playing musical instruments (15%), singing (27%), doing hobbies (64.0%), and others (51.8%). Most did not reply on question whether they achieved their self-actualization target of their lives, this might result from the fact that this was rather an abstract question. Our first part study revealed some characteristics of long-lived Thai physicians that seem to be in agreement with other studies indicating that physicians compared favorably with the general population in mortality from physical illness. This may result from several factors: the medical student selective process leading to “healthy worker effect”, knowledge in medicine, access to care, and their healthy behaviors (such as nutrition, exercise, religious activities which help improve their spiritual well-being).

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