Bringing Mindfulness into Medical Practice: UBC’s New Family Medicine Residency Program Delivers Mindfulness–Based Stress Reduction Curriculum

Devon Christie

This summer, four R1 Rural Family Medicine residents will commence their postgraduate training in the inaugural UBC Kootenay Boundary Rural Family Medicine residency program. As part of their Behavioural Medicine curriculum, they will participate in a 6–week Mindful Stress Reduction program, an adaptation of the traditional 8–week Mindfulness Based Stress Reduction (MBSR) program that was founded at the University of Massachusetts in 1979 by Jon Kabat–Zinn. MBSR has been subject to numerous RCTs and meta–analyses showing its effectiveness to alleviate symptoms and improve quality of life in cancer, cardiovascular disease, chronic pain, depression, anxiety disorders, and in prevention in healthy adults and children.[1-4].

A 2013 review identified 14 medical schools that offer mindfulness programs, including McGill, Brown, Georgetown, Duke, and Harvard.[5] Only two of those institutions incorporated mindfulness as a mandatory component of their undergraduate medical curricula: University of Rochester and Monash Medical School (Australia).[5] The Kootenay Boundary program will likely be the first postgraduate family medicine program to incorporate training in mindfulness into its core curriculum, in partial fulfillment of the curriculum’s mandate for innovation. A recent publication shows that interest in mindfulness training among medical students is higher in those who are in clinical (72 %) vs. preclinical (53 %) stages of their training, which supports the integration of mindfulness into a postgraduate core curriculum.[6]

What is Mindfulness?

Mindfulness refers to a capacity of mind, whereby one attends to his or her immediate experience arising both from within (e.g. mental states, thoughts, feelings, somatic sensations) and from our environment (e.g. auditory, visual, relationships, home, and work conditions) through vigilant observation while bearing the attitudes of kindness, acceptance, and non–judgment. In Kabat–Zinn’s concise words, “paying attention, on purpose, in the present moment, without judgment.”[7] Mindfulness is often learned through meditation, but is not equivalent to it.[8] Meditation describes varied formal practices (e.g. breath awareness, vocalizations/chanting, mantra, movement/yoga, lovingkindness/metta) whereby one practices sustaining attention in the present, thereby cultivating mindfulness. In the MBSR program, formal practices include the body scan, yoga, walking meditation, focused–attention meditations (e.g. to breath, sound, body sensations), and a form of open–monitoring meditation known in MBSR as “choiceless awareness.”

Mindfulness has recently become a buzzword, owing largely to increasing media coverage and burgeoning literature, as exemplified by recent CBC coverage of a UBC study published January 2015 showing that mindfulness decreased stress and improved optimism and math abilities of grade four and five students in Coquitlam, B.C.[9] A PubMed search of the term mindfulness returned 2231 citations published in the last ten years. By comparison, there were only 115 studies published in the preceding decade.

Why Teach Mindfulness to Physicians?

A Balm for Burnout

There is rising awareness about increasing rates of burnout among physicians, including estimates of up to 50 % among residents, regardless of year of training.[10] A 2015 US survey revealed 50 % of family physicians are burnt out, a number that increased from 43 % in 2013.[11] The estimated costs of burnout among Canadian physicians is $ 213.1 million, with family physicians accounting for 58.8 % of the costs.[12] (12). While burnout is not a recognized disorder in The Diagnostic and Statistical Manual of Mental Disorders, the World Health Organization International Classification of Diseases (ICD–10) defines burnout as “a state of vital exhaustion.”[13] Burnout has three measurable dimensions: emotional exhaustion from overwhelming work demands, depersonalization (impersonal response toward patients or coworkers), and perceived lack of personal accomplishment.[13] Burnout can lead to anxiety, substance abuse, depression, addiction, and suicide.[14] Suicide is the only cause of death that is higher in physicians than the general population, and while rates are higher in both genders compared to all other professions, the rate in female physicians is an incredible 250-400 % higher than the general population.[15] Mindfulness is one of the few self–care practices with evidence of benefit for physician wellness.[16] Encouraging studies show that mindfulness and meditation may play a protective role in the prevention and management of burnout.[17] Medical students who participate in mindfulness programs develop reductions in psychological distress and burnout, and increased capacity for empathy.[5] One week of compassion meditation training was found to counterbalance empathy fatigue and was accompanied by corresponding changes in the regions of the brain associated with compassion, positive emotions, and affiliation, thus supporting this as a possible coping strategy when confronted with distress of others.[18]

Improved Safety in Patient Care

Studies also show that physician well–being affects patient care.[19] Physicians have a professional obligation to maintain good health and practice good medicine, including making correct diagnoses and appropriate therapeutic decisions.[13] Research shows meditators have improved perception, increased reaction–time consistency, decreased reactivity to stressful stimuli, faster return to baseline activity after stress arousal, decreased activity in anxiety–related brain regions (amygdala, insular cortex), better control in buffering physiological responses to stressors (inflammatory and stress hormones), and even shrinkage of the amygdala over longer periods of practice.[20] The Canadian Medical Protective Association Good Practices Guide recommends physicians “improve self–awareness and mindfulness”—including recognizing fatigue, being alert to emotions, and recognizing that stress may interfere with reasoning—in order to increase situational awareness, one of the human factors that supports safe care and reduces medico–legal risk.[21]

Self-Awareness and Relationship–Centred Care

The CFPC Principles of Family Medicine states, “family physicians have an understanding and appreciation of the human condition, especially the nature of suffering and patients’ response to sickness. They are aware of their strengths and limitations and recognize when their own personal issues interfere with effective care.”[22] Self–awareness is the key to truly understanding the human condition and the nature of suffering, and it can be cultivated through mindfulness. Furthermore, mindful practitioners can attend to their own physical, mental, and emotional processes during patient encounters, enabling them to internally self–regulate while listening attentively and acting with “compassion, technical competence, presence, and insight.”[23] This ultimately fosters a cultural shift from patient–centred care, where physicians tend to focus solely on the needs of the patient, to relationship–centred care.[24] This reorientation toward mutuality highlights not only what we give but also what we receive in our practice, and increases both patient and physician satisfaction, and resilience.[25,26]

Medical training asks students who are often perfectionistic at baseline to acquire an overwhelming amount of knowledge in an environment of cross–examinations and occasional real abuse,[27,28] while at the same time being exposed to highly emotionally charged and sometimes horrific situations in a culture void of routine psychological and emotional integration opportunities.[29] This commonly leads to patterns of emotional distancing and repression, to sacrificing one’s own wellness, and eventually, to burnout. If not addressed prior to entering one’s career, these patterns can only provide a disservice to doctor and patient alike. It is imperative that medical curricula evolve to formally incorporate elements such as mindfulness practice that can serve to redress these patterns and plant the seed for lifelong attitudes and behaviours that foster physician self–awareness and well–being. This year, in line with leading medical institutions worldwide, UBC will be taking this step in Family Medicine training.

DISCLOSURES

Dr. Christie is a member of the clinical faculty at UBC, providing instruction to the UBC Kootenay Boundary Rural Family Medicine residency program. She has been involved in curriculum planning for the residency program as outlined in the article. She is also involved in planning a mindfulness and resilience program for healthcare providers at the Kalein Hospice Centre, where she works as a faculty member. She teaches mindfulness based stress reduction (as an MSP-funded group medical visit, where medically indicated) to patients. Dr. Christie also receives no compensation from any private parties.

REFERENCES
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Christie D. Bringing Mindfulness into Medical Practice: UBC’s New Family Medicine Residency Program Delivers Mindfulness–Based Stress Reduction Curriculum. UBCMJ. 2015: 7.1 (13-15).