Academy Society Spotlight: Mindfulness in the Medical Field
July 2019 Issue
Healthcare organizations are under increasing pressure to cut costs, increase productivity, and meet or exceed revenue goals. Physicians and other medical specialists are feeling pressure to take on more patients, work longer hours, and adapt to changing documentation requirements. As baby boomers hit retirement age, there will be a greater number of patients who require care for chronic conditions and not enough healthcare providers to meet their needs.1
All of these factors are placing stress on medical and allied healthcare clinicians. When not addressed or managed appropriately, stress can lead to depression, burnout, high blood pressure, anxiety, and loss of interest, compassion, and empathy toward others.2,3 Unfortunately, not all medical professionals are being taught how to handle stress and maintain balance in their personal and professional lives.
The Effect of Stress on Humans and Animals
Robert Sapolsky, PhD, neuroendocrinologist, professor, and author, has studied the effects of stress on animals and humans for more than 30 years. He describes what happens to the body during a stress response in his book Why Zebras Don't Get Ulcers:
During a stress response the cardiovascular system reacts by activating the sympathetic nervous system and turning down the parasympathetic nervous system. During this time, there is a large increase of glucocorticoids and adrenaline, or epinephrine, in the system... which activates the neurons in the brain stem that stimulate the nervous system and enhances the effects of epinephrine and norepinephrine on the heart muscle. The force of the heartbeat is increased as a result. When the force of the blood returns to the heart, it damages the muscles of the left side of the heart like a wall protecting an island from a hurricane. Eventually this side of the heart enlarges because of built up muscle tissue which can cause left ventricular hypertrophy.
Sustained elevated blood pressure damages the arterial branches where the fluid divides, or bifurcates. The smooth lining of the vessels can then tear or form craters, causing an inflammatory response. Epinephrine causes the circulating platelets to clump together and build up at the bifurcation points. Stress also causes fat, glucose, and LDL or "bad" cholesterol levels to build up as well. This is called atherosclerotic plaque. When the plaque is loosened, it is called a thrombosis, which can break away, travel into the coronary artery and cause a heart attack. If it travels to the brain, it can cause a stroke.4
In his animal studies, Sapolsky found that some animals turn on their stress response only when they need to get away from something that wants to kill them or when they want to eat.3 Immediately afterward, the animal's stress response stops. In animals with a hierarchical social structure, like baboons and macaque monkeys, stress response is directly related to the animal's social status. Higher status dominant males, for example, experience less stress and have less plaque in their arteries than lower status males. Sapolsky found there was an abundance of arthrosclerosis build up in baboons and macaques that experience chronic stress.4
These findings are significant because there are physiological similarities in how stress impacts humans. While the effects may not be immediately apparent, the amount of time and the conditions under which humans experience stress at work can have a negative impact on health.
The Impact of Stress on Medical Professionals
In the medical profession, chronic stress can result in sleep deprivation, make it more difficult to feel empathy toward patients, and lead to documentation mistakes, errors, impaired technical performance, and ultimately burnout. Burnout is characterized by emotional exhaustion, depersonalization, and feelings of low personal accomplishment.5 For medical practitioners, emotional exhaustion refers to the depletion of one's emotional and physical resources, which makes them feel drained. This can result in treating patients like objects rather than people. Research shows that chronic stress may lead to depression and even suicide.3
Fortunately, there is an increasing awareness among healthcare professionals about stress and burnout, and more healthcare employers are providing tools and resources to help medical practitioners deal with stress in the workplace.6,7
Mindfulness-based Stress Reduction
The practice of mindfulness is gaining attention as a way to deal with stress. A search of the MEDLINE database for articles between 1995 and 2000 that include the words "mindfulness" and "stress" resulted in 18,356 hits; between 2000 and 2005 this number grew to 29,678; between 2010 and 2015 the number increased to 67,820; between 2015 to 2019 the number of hits already totals 60,059. More than likely, this is due to the evidence that links mindfulness practice with a significant reduction in the likelihood for a relapse into depression.8
Mindfulness-based stress reduction (MBSR) is currently being taught as part of the medical school curriculum at Monash University, Australia; the University of Rochester; Harvard Medical School; and McGill University, Canada. Students explore what it means to be mindful as well as what happens when a person is not mindful (i.e., distraction, disengagement, and inattention). They are introduced to cognitive practices that can help them recognize how they perceive themselves and the world around them and learn techniques for nonattachment (letting go), acceptance, and presence of mind.
Mindfulness in O&P
The role of the O&P clinician involves more than device design and provision; clinicians also help facilitate emotional and psychological healing simply by being present. Students and clinicians are taught to question anything that is not evidence based or peer reviewed; however, mindfulness cannot be measured or quantified. Although the mechanisms through which mindfulness works are not fully understood, there are studies that point to positive results when mindfulness is brought into the medical field. Dobkin et al. conducted a prospective study with 25 clinicians who enrolled in an MBSR course.9 The physicians were tape-recorded with the same patient before and after the program, and the patients were asked to rate the quality of both encounters. The patients' ratings of the physician encounter that took place after the physicians had taken the MBSR course increased in the following three areas: interest in the patient as a person, understanding the patient's experience of illness, and attention to context. The physicians completed online questionnaires before and after the MBSR course. The scores were analyzed to determine whether there were changes in stress, depression, burnout, meaningfulness, and mindfulness (subscales: nonreactivity, nonjudgement, and act with awareness). The results showed a significant decrease in physician stress due to three facets of mindfulness: acting with awareness, nonreactivity, and nonjudgement.9
What Is Mindfulness Practice?
Mindfulness practice is the simple act of paying attention and being present in each moment. Mindfulness practice involves understanding what can and cannot be controlled and having a deeper sense of self-awareness and situational awareness. By incorporating mindfulness into clinical practice, O&P clinicians can communicate with more awareness and balance, which can benefit their professional and personal lives.
Why Teach Mindfulness?
Practitioners see multiple patients, fill out large amounts of paperwork, write detailed orders, do lab work, manage other employees, and negotiate with outside vendors, all while working to meet quotas and balancing home and family needs. It is easy for busy practitioners to become distracted and not provide the attention and awareness patients need and deserve. Patients can tell when their healthcare providers are not actively listening; when this happens, they shut down and withhold pertinent information. Patients are also less likely to listen attentively and adhere to practitioner recommendations. Practicing mindfulness helps increase practitioners' empathy and curiosity so that they can be more attentive to the patient's narrative. Practicing mindfulness helps practitioners' productivity and helps to positively manage the stressors that come with working in any clinic.
Epstein proposed the inclusion of four mindful habits, which can lead to clear, insightful actions and enhance a clinician's ability to provide competent, quality patient care: 10,11
Healthcare providers are under increasing stress due to greater productivity expectations. Burnout has been linked to higher blood pressure, cardiovascular disease, and psychological stress. Burnout is marked by decreased feelings of personal accomplishment, emotional exhaustion, and depersonalization. Teaching mindfulness to medical and allied healthcare practitioners can help these professionals deal with stress and negative emotions more productively and reduce the incidence of job burnout.12 Practicing mindfulness can help practitioners achieve balance in their personal and professional lives, which will result in increased levels of fulfilment in both realms.
Elicha D. Roberts, MSPO, is prosthetic resident at Audubon Orthotics and Prosthetics Services, Colorado Springs, Colorado.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.