May 6, 2011

McGill Programs in Whole Person Care

Dr. Patricia Dobkin

in collaboration with

Julie Irving (PhD candidate)

& Dr. Tom Hutchinson

Mindful Medical Practice: Mindful Medical Practice: Where are we NOW?Where are we NOW?

Students @ McGill Programs in Whole Person Care

Funding: SSHRC – Julie Ann Irving Programme d’aide aux médecins de Québec-Prends soin de soi- AstraZeneca (CSSS)

Questions to ponder:Questions to ponder:

1. For whom?

2. When?

3. Format?• Workshop• 8-week standard program• Weekend retreat

Teach Research Clinical Initiative

MDs &HCPs

Medstudents Public

McGill Programs In Whole Person Care

Patients

Evidence of lack of balanceMedical Students

Students selected in part because of diverse interests and skills

Become very focused on medical training

Little reinforcement for maintaining balance

Non-medical interests put on “back burner”

High incidence of depression and divorce

Evidence of lack of balanceResidents

Very long, exhausting work shifts

High responsibility for very sick patients

Little time or energy remains to pursue outside interests

High incidence of depression, suicidal ideation and divorce

Evidence of lack of balancePracticing Physicians

Pattern of over-working often continues

Reinforced and rewarded by employers

Little time for interests outside of medicine

High incidence of depression and burn out

Evidence of balance or lack there of in YOU please speak with the person next to you and share:

One example of balance

One example of imbalance

Mindfulness for Clinicians Mindfulness for Clinicians What have we done?What have we done?

One day workshops for healthcare practitioners 8 week courses for healthcare practitioners 4 week electives for 4th year medical students One day workshops for 2nd year medical

students 8 week course for family medicine residents

Published work on mindfulnessPublished work on mindfulness

See HandoutSee Handout

Mindfulness-Based Stress ReductionMindfulness-Based Stress Reduction

Kabat-Zinn et al. U Mass. Medical School – Modified for MDs and PhDs

8-week Group Program (26 hours)– body scan, sitting meditation– mindful yoga, walking meditation– group dialogue– stress management– CDs: home practice manual/exercises– silent retreat day

Psycho-educational group format Variation of meditation techniques Didactic material & daily home practice Eight weekly meetings of 2.5 hours Silent retreat between weeks 6 & 7

Core elements from MBSRCore elements from MBSR

Unique elements of MBMPUnique elements of MBMP

Role plays and other exercises focused on interpersonal mindfulness

Emphasis on communication, Satir stances (also Kramer 2007; Krasner et al., 2009)

Self-care highlighted Bilingual

Mindful Clinical EncounterMindful Clinical Encounter

Medical System

Social System

A

B

Health Care Professional

Patient/Person

Disease

C D

Role PlaysRole Plays

• Mixed-Method

• Concurrent triangulation design

QualitativeGrounded Theory

QuantitativePre-Post

ResearchResearch

Study 1 Study 2

Quantitative MeasuresQuantitative Measures

Outcomes•The Maslach Burnout Inventory•CES-D/BECK Depression •Perceived Stress Scale-10 •Psychological Well-Being

Process•Mindful Attention Awareness Scale •Self-Compassion Scale

38 MDs = 48%

Family, palliative medicine, pediatrics, etc. 18 PhDs = 23% 23 other (RN, MSc) = 29% 74% women; 26% men Mean age = 47.6 (SD= 12.5) 15% pre-MBMP screened + depression

(CES-D; BECK)

Sample characteristicsSample characteristics2008-2010 Clinicians 2008-2010 Clinicians (N= 81)(N= 81)

Study 2:Study 2: Focus Group QuestionsFocus Group Questions

1. What are the experiences of health professionals who participated in the MBMP program, including perceived challenges and benefits?

2. How does mindfulness practice effect health professional’s ability to cope with daily and work-related stressors?

3. Does mindfulness practice impact clinical work with patients and/or clients? If so, how?

Data Collection Plan over 2 Years Data Collection Plan over 2 Years (J. Irving doctoral thesis)(J. Irving doctoral thesis)

Cohort 2 Spring 2009 (n = 24)

Cohort 1 Spring 2008 (n = 27)

Results p < 0.0001Results p < 0.0001Health care professionalsHealth care professionals

Average to lowburnout

Results p < 0.0001Results p < 0.0001Health care professionalsHealth care professionals

Predictor Well-beingPredictor Well-being

β p

Model AModel A

1. Perceived Stress -.492 .892

2. Mindfulness 20.281 .035

3. Mindfulness x Perceived Stress -.385 .635

Model BModel B

1. Perceived Stress -1.190 .495

2. Self-Compassion 23.755 .003

3. Perceived Stress x Self-Compassion -.076 .518

Study 1: Regression Analyses BootstrapStudy 1: Regression Analyses Bootstrap

Follow-up QuestionnaireFollow-up Questionnaire

N Mean SD

Overall rating of MBMP (Importance) 72 8.27 1.58

Course Components:

Awareness of breath 79 8.67 1.63

Silent retreat 74 8.35 2.06

Small group exchanges 79 7.66 1.82

Sitting meditation without CD 77 7.58 2.00

Large group discussions 79 7.5 2.00

Home practice manual and exercises 79 7.33 2.09

Yoga with CD 78 7.28 2.60

Sitting meditation with CD 76 6.94 2.67

Body scan with CD 78 6.92 2.68

Body scan without CD 76 6.30 2.57

Standing YogaStanding Yoga

Thoughts

Feelings

Bodily Sensations

Pay attention to what happens to your:Pay attention to what happens to your:

Data analysis followed the steps outlined by Kruger (2007):1. Open coding: read the transcripts in their entirety and

search for important general, overarching themes.

2. Note emerging themes question by question, and through the transcript as a whole, line by line.

3. Developing coding categories and applying them to the transcripts

4. Create diagrams to illustrate themes and inter-relatedness or processes.

5. Revisit and review sections of data which have been omitted.

6. Systematically report results based upon the research questions.

Grounded Theory AnalysisGrounded Theory Analysis

Enhanced Awareness

Internal and External

Landscape

Mindfulness Practice

Focus, Observe, Accept, Change

Group Culture & Modeling

Self & Others

CONTEXT

CAUSAL CONDITIONS

INTERVENING CONDITIONS

CORE PHENOMENON

ACTION/INTERACTION STRATEGIES

CONSEQUENCES

Awareness Inattention

Internal and External Landscape

Mindfulness Practice

Focusing on senses

Group Culture & Modeling

Self: Enjoying walk to work

CONTEXT

CAUSAL CONDITIONS

INTERVENING CONDITIONS

CORE PHENOMENON

ACTION/INTERACTION STRATEGIES CONSEQUENCES

Example: 1Example: 1

P12: A very big change…. We discover, I’ve discovered surprising emotions. Like the joy that comes from walking down the street, observing the trees, looking at the clouds. I’ve rediscovered beauty also. The present moment is like a song being sung.

Awareness “need to fix”

Internal and External Landscape

Mindfulness Practice

Observe, Be with

Group Culture & Modeling

Self & Other: Create space, let go of my agenda, convey empathy

CONTEXT

CAUSAL CONDITIONS

INTERVENING CONDITIONS

CORE PHENOMENON

CONSEQUENCES

Example: 2Example: 2

P6: It’s a new territory for me in my everyday practice that, and I think I am able to listen better to what people have to say because I am trying to really just be there as oppose to “o.k. I have a role to play, I’m here to listen but I have to fix you”. And I noticed that when I have this experience that even if something difficult happened there was a very empathetic interaction. I think I didn’t have a plan that I came in with and I just … I just was present and that worked, by itself.

ACTION/INTERACTION STRATEGIES

Data Triangulation Data Triangulation Quantitative and QualitativeQuantitative and Qualitative

Mindful Awareness = increased from both perspectives

Common Humanity = increased from both perspectives

Isolation = decreased from both perspectives

Self-Compassion = increased from both perspectives

Can this “process” be captured in 8-weeks?

Themes in common with other qualitative studies with clinical populations:Importance of group experience and sense of universality P6: There were some times in the past that I felt very isolated and I had difficulties because I thought I was the only one having this problem, but just having a group experience and learning that other people have similar difficulties was so important. I am not alone. [n=19]

Centrality of acceptance P25: As for me, yes. I have a tendency towards constant self-criticism because I would like to be perfect. More and more, I accept myself the way I am, because this is who I am. [n= 12]

Some degree of frustration and/or distress identified as part of learning process P13:When you do a lot meditation its kind of, you are kind of like cleaning out the drawers and you notice a lot of stuff that comes up. Some of it is great and some is negative memories, things, and emotions that come up and when they’re on there way out, you know, it’s kind of like doing a detox. [n=14]

Data TriangulationData Triangulation

Perfectionism P24: “Since health care workers seek perfection… I wouldn’t allow myself to make any mistakes while meditating. I had to repeat to myself that I didn’t have to be perfect here”. [n=10]

“Helping/Fixing mode” P3: As a clinician, I always had a hard time seeing what my role was, even though I was told we weren’t fixing anything, I always felt that my patients were coming to me to have something fixed. And my expectation of myself was that I was supposed to do something. They were coming to me for a reason and if they are not getting better then I’m not doing something. And I think I came to realize this more and more and it kind of confirmed, like I started to realize that part of my job was to be there with patients... this kind of confirmed for me just being there in the present moment and with their experience is, is very powerful. [n= 8]

Other-focus P17: It made me realize how good I am at listening to others… Also, that listening to others is kind of a way of not talking… when I was talking about something that was difficult in the group, as soon as my partner started to talk I forgot all the difficult thing that I was talking about. So I realized, this is a great way not to think of a difficult thing when you are focused on the other. And so that became very clear to me, that there may be a reason why I am such a good listener. [n=7]

Process themes Process themes uniquely highlighteduniquely highlighted by health care professionals:by health care professionals:

Awareness of Breath

Sample characteristics (2009-11)Sample characteristics (2009-11)4th year medical students (N= 46)4th year medical students (N= 46)

“Physicianship” elective 2009: n = 15 2010: n = 17 2011: n = 14 Modified to fit elective schedule (1 month) Shorter meditation CDs

Medical students’ results (n=46)Medical students’ results (n=46) Significant pre-post changes:

– Self-compassion– Mindfulness– Stress

* p<.007** p<.0001

2.76 3.25 3.5 3.93

17.71

14.87

SCS-total ** MAAS** PSS*

Physicianship 4 (INDS 420) Physicianship 4 (INDS 420) Medicine & Society elective evaluationMedicine & Society elective evaluation

Poor Below Average

Satisfactory Good Excellent

Interest 00%

00%

49.1%

1329.5%

2761.4%

Structure 00%

00%

36.8%

1022.7%

3170.5%

Physicianship 4 (INDS 420) Physicianship 4 (INDS 420) CommentsComments

“I think there should not be a cap to the size of this class. Every student who wants this opportunity should be allowed to choose it…”

“Excellent class. Only minor change I would request it to leave out breaking the silence during the retreat day and let us leave in silence to break the silence in our own time.”

“Positive impact on my perspective and acceptance. I hope to carry these skills with me throughout my practice. Would like more yoga. […] Enjoyed SIM Centre too.”

La Pratique médicale et la pleine conscienceLa Pratique médicale et la pleine conscienceUn programme pour les résidents en médecine en collaboration avec le Centre de santé et de services sociaux des Faubourgs.

* p<.001** p<.002*** p<.006****p<.005

N=15

MERCI Drs Gough et Rajotte

Questions to discuss:Questions to discuss:

For whom? When? Format?

– Workshop– 8-week standard program– Weekend retreat

Where to NEXT?Where to NEXT?

SIM centre assessment of communication Weekend retreats (next week in Ottawa) Monthly follow-up 2 hour classes Conference workshops (Bromont 09/2011) Canadian Space Agency Collaboration with Dr Robert Béliveau Other?