In 2011, the Mayo Clinic began surveying physicians about burnout and found 45% of physicians experienced at least one symptom, such as emotional exhaustion, finding work no longer meaningful, feelings of ineffectiveness, and depersonalizing patients. Associated manifestations can range from headache and insomnia to impaired memory and decreased attention.
Fast forward 10 years to the Medscape National Physician Burnout and Suicide Report, which found that a similar number of physicians (42%) feel burned out. The COVID-19 pandemic only added insult to injury. A Medscape survey that included nearly 5000 US physicians revealed that about two thirds (64%) of them reported burnout had intensified during the crisis.
These elevated numbers are being labeled as "a public health crisis" for the impact widespread physician burnout could have on the health of the doctor and patient safety. The relatively consistent levels across the decade seem to suggest that if health organizations are attempting to improve physician well-being, it doesn't appear to be working, forcing doctors to find solutions for themselves.
Jill Wener, MD, considers herself part of the 45% burned out 10 years ago. She was working as an internist at Rush University Medical Center in Chicago, but the "existential reality of being a doctor in this world" was wearing on her. "Staying up with the literature, knowing that every day you're going to go into work without knowing what you're going to find, threats of lawsuits, the pressure of perfectionism…" Wener told Medscape Medical News, trailing off. "By the time I hit burnout, everything made me feel like the world was crashing down on me."
When Wener encountered someone who meditated twice a day, she was intrigued, even though the self-described "most Type-A, inside-the-box, nonspiritual type, anxious, linear-path doctor" didn't think people like her could meditate. Wener is not alone in her hesitation to explore meditation as a means to help prevent burnout because the causes of burnout are primarily linked to external rather than internal factors. Issues including a loss of autonomy, the burden and distraction of electronic health records, and the intense pressure to comply with rules from the government are not things mindfulness can fix.
And because the sources of burnout are primarily environmental and inherent to the current medical system, the suggestion that physicians need to fix themselves with meditation can come as a slap in the face. However, when up against a system slow to change, mindfulness can provide physicians access to the one thing they can control: how they perceive and react to what's in front of them.
At the recommendation of an acquaintance, Wener enrolled in a Vedic Meditation (also known as Conscious Health Meditation) course taught by Light Watkins, a well-known traveling instructor, author, and speaker. By the second meeting she was successfully practicing 20 minutes twice a day. This form of mediation traces its roots to the Vedas, ancient Indian texts (also the foundation for yoga), and uses a mantra to settle the mind, transitioning to an awake state of inner contentment.
Three weeks later, Wener's daily crying jags ended as did her propensity for road rage. "I felt like I was on the cusp of something life-changing, I just didn't understand it," she recalls. "But I knew I was never going to give it up."
"Mindfulness is being able to be present in the moment that you're in with acceptance of what it is and without judging it," says Donna Rockwell, PsyD, a leading mindfulness meditation teacher. The practice of mindfulness is really meditation. Rockwell explains that the noise of our mind is most often focused on either the past or the future. "We're either bemoaning something that happened earlier or we're catastrophizing the future," she says, which prevents us from being present in the moment.
Meditation allows you to notice when your mind has drifted from the present moment into the past or future. "You gently notice it, label it with a lot of self-compassion, and then bring your mind back by focusing on your breath — going out, going in — and the incoming stimuli through your five senses," says Rockwell. "When you're doing that, you can't be in the past or future."
Rockwell also points out that we constantly categorize incoming data of the moment as either "good for me or bad for me," which gets in the way of simply being present for what you're facing. "When you're more fully present, you become more skillful and able to do what this moment is asking of you," she says. Being mindful allows us to better navigate incoming stimuli, which could be a "code blue" in the ER or a patient who needs another two minutes during an office visit.
When Wener was burned out, she felt unable to adapt whenever something unexpected happened. "When you have no emotional reserves, everything feels like a big deal," she says. "The meditation gave me what we call adaptation energy; it filled up my tank and kept me from feeling like I was going to lose it at 10 o'clock in the morning."
Rockwell explains burnout as an overactive fight or flight response activated by the amygdala. It starts pumping cortisol, our pupils dilate, and our pores open. The prefrontal cortex is offline when we're experiencing this physiological response because they both can't be operational at the same time. "When we're constantly in a 'fight or flight' response and don't have any access to our prefrontal cortex, we are coming from a brain that is pumping cortisol and that leads to burnout," says Rockwell.
"Any fight or flight response leaves a mark on your body," Wener echoes. "When we go into our state of deep rest in the meditation practice, which is two to five times more restful than sleep, it heals those stress scars."
Making Time for Mindfulness
Prescribing mindfulness for physicians is not new. Molecular biologist Jon Kabat-Zinn, PhD, developed Mindfulness-Based Stress Reduction (MBSR) in 1979, a practice that incorporates mindfulness exercises to help people become familiar with their behavior patterns in stressful situations. Thus, instead of reacting, they can respond with a clearer understanding of the circumstance. Kabat-Zinn initially targeted people with chronic health problems to help them cope with the effects of pain and the condition of their illness, but it has expanded to anyone experiencing challenges in their life, including physicians. A standard MBSR course runs 8 weeks, making it a commitment for most people.
Mindfulness training requires that physicians use what they already have so little of: time.
Werner was able to take a sabbatical, embarking on a 3-month trip to India to immerse herself in the study of Vedic Meditation. Upon her return, Wener took a position at Emory University School of Medicine in Atlanta and has launched a number of CME-accredited meditation courses and retreats. Unlike Kabat-Zinn, her programs are by physicians and for physicians. She also created an online version of the meditation course to make it more accessible.
For these reasons, Kara Pepper, MD, an internist in outpatient primary care in Atlanta, was drawn to the meditation course. Pepper was 7 years into practice when she burned out. "The program dovetailed into my burnout recovery," she says. "It allowed me space to separate myself from the thoughts I was having about work and just recognize them as just that — as thoughts."
In the course, Wener teaches the REST Technique, which she says is different than mindfulness in that she encourages the mind to run rampant. "Trying to control the mind can feel very uncomfortable because we always have thoughts," she says. "We can't tell the mind to stop thinking just like we can't tell the heart to stop beating." Wener says the REST Technique lets "the mind swim downstream," allowing the brain to go into a deep state of rest and start to heal from the scars caused by stress.
Pepper says the self-paced online course gave her all the tools she needed, and it was pragmatic and evidence-based. "I didn't feel 'woo' or like another gimmick," she says. Pepper, who continues to practice medicine, became a life coach in 2019 to teach others the skills she uses daily.
An Integrated Strategy
Wener acknowledges that meditation is not the panacea for everyone's burnout, which data support. In a review published in The American Journal of Medicine in 2019, Scott Yates, MD, MBA, from the Center for Executive Medicine in Plano, Texas, found that physicians who had adopted mediation and mindfulness training to decrease anxiety and perceived work stress only experienced modest benefits. In fact, Yates claims that there's little data to suggest the long-term benefit of any particular stress management intervention in the prevention of burnout symptoms.
"The often-repeated goals of the Triple Aim (enhancing patient experience, improving population health, and reducing costs) may be unreachable until we recognize and address burnout in healthcare providers," Yates writes. He recommends adding a fourth goal to specifically address physician wellness, which certainly could include mindfulness training and meditation.
Burnout coach, trainer, and consultant Dike Drummond, MD, also professes that physician wellness must be added as the key fourth ingredient to improving healthcare. "Burnout is a dilemma, a balancing act," he says. "It takes an integrated strategy." The CEO and founder of TheHappyMD.com, Drummond's integrated strategy to stop physician burnout has been taught to more than 40,000 physicians in 175 organizations, and one element of that strategy can be mindfulness training.
Drummond says he doesn't use the word meditation "because that scares most people"; it takes a commitment and isn't accessible for a lot of doctors. Instead, he coaches doctors to use a 'single-breath' technique to help them reset multiple times throughout the day. "I teach people how to breathe up to the top of their head and then down to the bottom of their feet," Drummond says. He calls it the Squeegee Breath Technique because when they exhale, they "wipe away" anything that doesn't need to be there right now. "If you happen to have a mindfulness practice like meditation, they work synergistically because the calmness you feel in your mediation is available to you at the bottom of these releasing breaths," he adds.
Various studies and surveys provide great detail as to the "why" of physician burnout. And while mindfulness is not the sole answer, it's something physicians can explore for themselves while healthcare as an industry looks for a more comprehensive solution.
"It's not rocket science," Drummond insists. "You want a different result? You're not satisfied with the way things are now and you want to feel different? You absolutely must do something different."
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Cite this: Is Mindfulness Key to Helping Physicians With Mental Health? - Medscape - Nov 15, 2021.