September 23, 2009
Reducing Physician Burnout
Training also improves attitudes about patients and their care
Training in mindfulness meditation and communication can alleviate the psychological distress and burnout experienced by many physicians and can improve their well-being, University of Rochester Medical Center researchers report in today's issue of the Journal of the American Medical Association (JAMA).The training also can expand a physician's capacity to relate to patients and enhance patient-centered care, according to the researchers, who were led by Michael S. Krasner, M.D., associate professor of Clinical Medicine.
"From the patient's perspective, we hear all too often of dissatisfaction in the quality of presence from their physician. From the practitioner's perspective, the opportunity for deeper connection is all too often missed in the stressful, complex, and chaotic reality of medical practice," Krasner said. "Enhancing the already inherent capacity of the physician to experience fully the clinical encounter"”not only its pleasant but also its most unpleasant aspects"”without judgment but with a sense of curiosity and adventure seems to have had a profound effect on the experience of stress and burnout. It also seems to enhance the physician's ability to connect with the patient as a unique human being and to center care around that uniqueness.
"Cultivating these qualities of mindful communication with colleagues, anecdotally, had an unexpected benefit of combating the practitioners' sense of isolation and brought forth the very experiences that are such a rich source of meaning in the life of the clinician," he said.
Edward A. Stehlik, M.D., governor of the Upstate New York branch of the American College of Physicians and an internist who practices near Buffalo, said the training was "the most useful thing I've done since my medical training to help me in my practice of medicine."
"If you asked my patients, I think they would say I listen more carefully since the training and that they feel they can explain things to me more forthrightly and more easily," Stehlik said. "Even the brief moments with patients are more productive. Are there doctors who desperately need this training? Yes, absolutely."
Primary care physicians report high levels of distress. As many as 60 percent of practicing physicians report symptoms of burnout, which is defined as emotional exhaustion, treating patients as objects, and low sense of accomplishment, the authors of the JAMA article stated.
Physician burnout has been linked to poorer quality of care, including patient dissatisfaction, increased medical errors, and lawsuits, and decreased ability to express empathy. Substance abuse, automobile accidents, stress-related health problems, and marital and family discord are among the personal consequences reported.
Mindful communication utilizes the techniques of meditation to help people maintain an open and nonjudgmental outlook as they tackle everyday tasks. The training also included the use of narrative medicine, real stories from the clinician's practice of medicine.
Learning to increase one's awareness of thoughts, feelings, and sensations while exploring these narratives, the physicians also engaged in "appreciative dialogues" that focus on the capacities and skills used to successfully manage even the most challenging of clinical situations. For physicians, mindfulness and the exploration of clinical narratives helped them to be aware of how they are feeling, how events in their own lives might be influencing how they react to patients, and how they can better recognize the meaning and satisfaction derived from the practice of medicine, Krasner said.
Seventy physicians from the Rochester, N.Y., area were involved in the study and training. Before the training began, the physicians answered questions in a series of assessment surveys designed to measure burnout and empathy, characterize beliefs about patient care and profile personality and mood. The physicians answered similar questions during the course of the training.
The training involved eight intensive weekly sessions that were 2 Ã½ hours long, an all-day session and a maintenance phase of 10 monthly 2 Ã½-hour sessions.
A statistical analysis showed that the participating primary care physicians experienced improved well-being, including significant decreases in burnout and mood disturbance. They also experienced positive changes in empathy and psychosocial orientation to clinical care. These indicators of a patient-centered behavior together with the improvements in personal well-being reflect the combined interpersonal and the intrapersonal approach of mindful communication, and the importance of both for an effective and satisfying physician-patient relationship.
John K. Chamberlain, M.D., an internist and pediatrician in the Rochester area who participated in the training, said he often left the sessions "refreshed and satisfied about being a physician."
"I like to think it reinforced the need to continue to do what I was doing in the face of time pressures more than altered my approach," Chamberlain said. "That is a difficult self-appraisal question, and I suspect the answer again varied during the course of the program. It provided a framework and vocabulary to remain in the moment and diminish the proximate and remote experiences that might interfere with the therapeutic relationship, while stimulating awareness of the experiences that reinforced it."
"The most salient element was the collegial effect of weathered physicians reflecting on mutual experience using a theme-based approach in a safe environment," Chamberlain said. "It is a unique opportunity to return to our roots as physicians, exploring in a workshop format abstract yet key emotionally charged or difficult issues that many of us had not visited so academically since medical school. Perception of the impact and approach to those issues is quite different once tempered by experience, particularly in a program that emphasizes awareness of the moment. It is a singular opportunity to do-over some of our medical school experience, and get much more out of it than the first time, as one reflects on how others in the group have grappled with and addressed the complex experiences of being a physician whose life touches and is touched by others constantly. The program is all about the experience of being a physician. Not what to do, or how to do it, but what it feels like. That is unique, and quite refreshing."
The researchers concluded that a training program in mindfulness represents a model of medical education "that may help provide growth and sustenance to physicians in the service of promoting excellence in clinical care and professional satisfaction and well-being."
In addition to Krasner, the authors of the JAMA article include: Ronald Epstein, M.D., professor of Family Medicine; Timothy Quill, M.D., director of the Center for Ethics, Humanities, and Palliative Care at the Medical Center; Howard Beckman, M.D., medical director of Rochester Individual Practice Association; Anthony Suchman, M.D., clinical professor of Medicine; Benjamin Chapman, Ph.D., assistant professor of Psychiatry; and Christopher Mooney, M.A., Office of Medical Education, School of Medicine and Dentistry.
The study was funded by the Boston-based Physicians Foundation for Health System Excellence, and was sponsored by the New York Chapter of the American College of Physicians.
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