Burnout, an occupational syndrome included in the World Health Organization’s International Classification of Diseases, 11th Revision, has been defined as a “prolonged response to chronic interpersonal stressors on the job.”
Burnout contributes to surgeons’ medical errors and lapses in professionalism. Despite how widespread burnout, depression, and suicidality are among surgeons, evidence-based interventions that ease their debilitating effects remain scarce.
In an effort to fill this gap, researchers at the University of California, San Francisco (UCSF) have turned to mindfulness practices for solutions. Mindfulness is “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally,” according to Jon Kabat-Zinn, PhD, an emeritus professor of medicine at the University of Massachusetts Medical School who developed secular MBSR and is largely credited for introducing mindfulness into Western medicine. Previous studies suggest such mindfulness-based interventions can improve the resilience, affect, executive function, and performance among people in other high-stress professions.
In 2018, the UCSF team reported that tailored MBSR training was feasible and useful among 21 surgical residents in a pilot clinical trial. In their recent JNO follow-up study, the researchers analyzed the program’s effects on these trainees’ well-being and performance.
First-year surgical residents were randomized to modified MBSR training or an active control group. The MBSR group participated in an 8-week program that comprised weekly 2-hour classes and daily 20-minute home practice including body awareness, yoga, meditation, and transition breathing sessions. The control group had similar class-time and home-practice requirements that explored topics such as perseverance, honesty, self-care, and the ethos of surgery.
Using validated surveys and tests, the researchers measured postintervention changes in the following outcomes:
Perceived stress (primary)
Functional neuroimaging during an emotional regulation task
The MBSR group had half as much perceived stress and twice as much mindfulness as the control group, differences that were associated with medium to large effect sizes.
Motor performance and aspects of executive function, including working memory capacity, improved in the MBSR group compared with the control group. Associated effect sizes were medium to large.
In contrast, burnout increased to a similar degree in both groups.
Depressive symptoms increased twice as much in the control group compared with the MBSR group.
The MBSR group showed greater activation in brain regions associated with executive function and self-awareness during an emotional regulation task.
However, none of the changes in any outcomes were significantly different between groups. The study was not powered to detect such differences.
Given the study’s small sample size and single-institution setting, the results should be interpreted cautiously, the authors noted.
“The mindfulness exercises reported did not yield statistically significant differences between groups, suggesting that mindfulness itself may not be effective,” said Edward Livingston, MD, JAMA deputy editor and professor of surgery at UCLA, who was not involved in the study. However, because these are preliminary studies, the findings aren’t definitive, he added.
In an editorial accompanying the recent study, Brooke Gurland, MD, clinical professor of surgery at Stanford University, wrote that current surgical training doesn’t address “the emotional consequences of life-and-death decision-making or the impact of surgical complications on surgeon well-being.”
The surgical training culture has long rested on the notion that sleep deprivation, constant challenges, and brutalization were necessary to ensure that exhausted surgeons would be on autopilot to respond appropriately to dramatic events, Livingston explained.
The thinking went that “when a surgeon steps back to reflect on the experience of being a surgeon, there is a high likelihood he or she will crack, ” he said. “Mindfulness is a process of refocusing the brain, to take it out of autopilot mode.”
By switching off autopilot, mindfulness-based interventions may reduce stress and strengthen a person’s ability to tolerate uncomfortable experiences through cultivating nonreactivity to difficult thoughts, events, and emotions, according to the study authors.
Mindfulness-based stress reduction training may help mitigate stress and enhance executive function among surgeons, but larger, more definitive trials are needed, the authors wrote.
The take-away message is “that burnout and health care reform for physician well-being are of paramount importance” and the study’s tailored MBSR program “shows highly promising impact on stress and executive function,” lead author Carter Lebares, MD, assistant professor of surgery at UCSF, said in an interview.
Physician stress, burnout, depression, and other mental health concerns aren’t limited to surgical residents. Case in point: a recent survey of US ophthalmology residents found that 68.4% of respondents reported their program faced issues with depression, burnout, or suicide among trainees in the past year.
In recognition of this pervasive problem, the Accreditation Council for Graduate Medical Education (ACGME) recently introduced new requirements aimed at promoting a “culture of well-being” in physician training programs. The authors of the JNO study point out that mindfulness-based interventions are “a promising means to address [ACGME] programming mandates.”
However, the importance of the study may ultimately lie not in the specific intervention or outcomes, but rather in acknowledging that physicians are stressed and that this has adverse consequences, according to Livingston. “[T]he basic concept of addressing the stress surgeons experience and changing the culture of surgery so that it is allowable for surgeons to seek help is an important advance,” he added.
The researchers plan to test their MBSR intervention in larger populations of surgeons and in other contexts, such as the military and trauma, according to Lebares.
This content was originally published here.