May we please request that you sit beside and pair off with someone that you are less familiar with

Thank you!

Remaining Vital: Thriving in a challenging environmentTrevor Bon MD, FRCPC

Catharine Tombs, PT

Northern Constellations 2018

Disclosures

Trevor Bon:

I have no financial, academic or other competing interests

Catharine Tombs:

I have no financial, academic or other competing interests.

Safe Space Guidelines:

Exercises may be new and provoke some discomfort Beginner’s Mind- you’re not here to impress just be

you, allow yourself to explore Confidentiality Make “I” statements Inside voices out, outside voices in Respect differences If you can- turn off and put weapons of mass

distraction out of sight

Who is in room?

Physician’s ?Residents ?Health care

Practitioners?Others?

Exposure to mindfulness ?

Casual practitioners?

Dedicated practitioners?

Inspiration…

Participation in local Mindfulness-based Cognitive Therapy Program

Participation in Mindfulness-based Self-Compassion Workshop

Ongoing engagement with meditation and mindfulness practices

Participation in 2 day ‘Search Inside Yourself Leadership Institute’ Mindfulness-Based Emotional Intelligence for Leaders Training

We are not experts!

Outline:

Why Mindfulness in Medicine?

Literature on Mindfulness in Medicine

Neuroscience

Mindfulness Practices

Discussion & Reflection

Mindfulness Exercise:3 Minute Breathing SpacePURPOSE: Calms the mind and body when feeling ‘activated’ Allows focus on what’s most important now Settles the mind and ‘change gears’ or ‘clear the slate’ Regulates the nervous system- Neurological ‘reset’ Increases vagal tone

Micro practice: 3 Mindful Breaths Useful way to recognize transitions in the day

Mindfulness Exercise:3 Minute Breathing Space-Reflection

What effect did this have on you?

Do you use this practice now? When?

If not, how do you think this could be useful to you? When?

Embodied Mindfulness(Formal/Informal Practices)

Self-awarenessEmotional Intelligence

Focussed AttentionNervous System Regulation

Personal ResilienceCompassion

The Stressors: Busy, face-paced Attentional challenges ENVIRONMENT

Aging, medically-complex Emotional challengessuffering PATIENTS Compassion challenges

CULTURE of bravado and Emotional suppressionSelf-critical attitude

High-achieving, Self-Care & Self-Compassion perfectionistic challengesSelf-sacrificingMINDSET

Fear of showing weakness or Authenticity challengesvulnerability, denial of burnout Mental health challenges

Physician Burnout: “Erosion of the soul” Emotional exhaustion, depersonalization, and low sense of personal

accomplishment

29% of physicians, 38% residents

Depression (% screening positive): 33% physicians, 49% residents

Completed suicide rates are 1.4-2.3 X Canadian general population

300 doctors on disability out of 17 000 insured by OMA group disability, number one cause mental health

CMA , National Physician Health Survey, 2017, Simon C, McFadden, T

Maslach C, Jackson S, Leiter M: Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, Calif, Consulting Psychologists Press, 1996

Maslach’s burnout scale: https://www.mindtools.com/pages/article/newTCS_08.htm

Ripple Effects of Burnout

SYSTEMIC IMPACT

Potential for increased medical errors

Impact on patient care

Patient satisfaction

Patient recovery times

Impact on health system

PERSONAL IMPACT

Relationship difficulties

Substance use

Suicidal ideation

Increase in divorce rates

Mental health disorders

Burned Out Resilient

1 2 3 4 5 6 7 8 9 10

Withdrawn Present

Defeated Bouncing back

Going through the motions Fully engaged

Rigid Bending, not breaking

Cynical, hopeless Capacity for positivity

Hypercritical A light touch

Feeling ineffective Becoming stronger

Treading water Moving forward

Fearing change Welcoming change

Source: Attending: Medicine, Mindfulness and Humanity

Ronald Epstein, M.D.

Mindfulness Exercise:Self-Care ‘Check-In’

PURPOSE:

Barometer of how you are doing

Way to develop self-awareness through tuning in to the body

Develops sense of impermanence of thoughts/emotions

Awareness of what your mind is practising

Micro practice: Head-Body-Heart Check in

1st breath HEAD- What are my thoughts?

2nd breath BODY- What emotions & intuitions are present?

3rd breath HEART- What are my values & intentions?

Mindfulness Exercise:Self-Care ‘Check-In’- Reflection

What did you discover? Any surprises?

Do you think this could be useful to you? When?

Know thyself

“Your beliefs become your thoughtsYour thoughts become your wordsYour words become your actionsYour actions become your habitsYour habits become your characterYour character becomes your destiny”

Mahatma Gandhi

WELLNESS STRATEGIES:

STRESS RESILIENCE

Resilience Factors

Realistic Optimism

Facing fear

Moral compass

Religion & spirituality

Social Support

Role Models

Physical fitness

Brain Fitness

Cognitive & emotional flexibility

Sense of meaning & purpose

S.M. Southwick and D.S. Charney, Resilience: The Science of Mastering Life’s Greatest Challenges (Cambridge: Cambridge University Press, 2012

Mindfulness Moment-by-moment awareness of sensations, perceptions,

emotions and thoughts

Paying attention with curiosity and without judgement

Helps us relate to ourselves and others with compassion

Allows individuals to choose what they’ll strengthen and bring into action and what they’ll let go of

Greater sense of agency and control

Discernment of self vs. other’s emotions

Video: Mindfulness is a super power

https://www.youtube.com/watch?v=w6T02g5hnT4

Embodied Mindfulness(Formal/Informal Practices)

Self-awarenessEmotional Intelligence

Focussed AttentionNervous System Regulation

Personal ResilienceCompassion

The graph above represents the number of peer-reviewed publications as referenced by PubMed (through 2014). PubMed is a division of the US National Library of Medicine and the National Institute of Health. contemplativemind.wordpress.com

The graph above represents the number of grants awarded by the NIH through 2014 based on the RePORTER database. RePORTER indexes data and analyses of NIH research activities. contemplativemind.wordpress.com

Mindfulness Exercise:Mindful listening: Dyad Practice

Exercise Guidelines:Split into pairs

Sit across from one another facing each other with nothing between you

A talks, B listens without interrupting

Switch roles

Exercise Questions:1. What do you love about your work?

2. What challenges are you facing in your work?

Mindfulness Exercise:Dyad Practice

Debrief Questions:

1. How did you feel in each role?

2. Which role was more comfortable for you? Why?

3. What would it be like not to go into your ‘knee jerk’ reactions in dialogues?

4. How might your reflections on this exercise serve you in your work?

Embodied Mindfulness(Formal/Informal Practices)

Self-awarenessEmotional Intelligence

Focussed AttentionNervous System Regulation

Personal ResilienceCompassion

Developing ResilienceSelf-Compassion Practice

Bring to mind a recent difficult experience you encountered or a failure you experienced.

What happened? Who was involved?

How did you feel? How did you treat yourself?

Developing ResilienceSelf-Compassion Practice- Reflection

Discuss with a partner

How does the idea of self-compassion feel to you cognitively How did the practice feel in your body?

Is self-compassion something that is challenging for you? Why?

How can you be a better friend or ally to yourself in times of challenge?

Self-Compassion

Instead of mercilessly judging and criticizing

yourself for various inadequacies or shortcomings,

self-compassion means you are kind and understanding

when confronted with personal failings –

after all, who ever said you were supposed

to be perfect?

Kristin Neff

Self-compassion.org

Compassion

From the Latin word compati meaning to ‘suffer with’

Components:

1. Cognitive = “I understand you” RELATE

2. Affective = “I feel with you” RESONATE

3. Motivational = “I want to help you” ACT

Compassion is a trainable skill

Hippocratic Oath

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

Principles of beneficence and non-maleficence not only in the care of patients, but also for ourselves

“If your compassion does not include yourself, it is incomplete.”

—Jack Kornfield

Why is compassion important?

Improves health and well-being in relationships Increases resilience in the face of suffering Helps prevent empathy (compassion) fatigue and vicarious

trauma Protective against loneliness and stress Reinforces motivation and values behind desire to become

a healer Improves patient outcomes

“Compassion is the heart of healthcare” - Pope Francis

Just Like Me

Human beings are ‘tribal’

Identification with people we see as ‘self’

Separation from those we see as ‘other’

Inability to see self in other = disconnection

Degrading of compassion

Developing ResilienceCompassion for others practice: Just Like Me

Bring to mind a recent interaction you had with someone difficult

What was the situation? Who was involved? How did you feel?

What did you assume in this situation about this person that was perhaps not true?

Developing ResilienceCompassion for others practice: Reflection

Talk with a partner

Was there a shift in your feeling toward this person during this exercise?

What changed? Was there any shift in the felt sense in your body while

doing this exercise?

How might you use this practice?

Brief Mindfulness Practices in Healthcare workers

Studies looking at effect of brief mindfulness interventions on provider well-being and behaviour

Studies found positive effect on levels of stress, anxiety, mindfulness, resiliency, and burnout symptoms

No studies reported differences in provider behaviour

Interventions: sitting meditation, breathing exercises, guided imagery, relaxation methods, yoga, or desensitization-relaxation in person or through virtual modalities

Brief Mindfulness Practices for Healthcare Providers – A Systematic Literature Review, The American Journal of Medicine, (2017) 130, 1219.e1-1219.e17

Mindfulness as measured by Electroencephalogram

Does mindfulness meditation work 56 studies (out of 284), 1715 subjects, looking for commonality on EEGs during

meditation

Study types: mindfulness compared to resting state and effects of mindfulness practice on EEG over time

Main finding: increased in alpha wave synchronization with mindfulness relative to a resting state and increased theta power during meditation compared to a resting state

Results were variable across studies

Alpha waves synchronization associated with greater ‘inner directed’ attention

Inner directed attention associated with better memory, imagination, improvement in attention networks in terms of focused-attention aspects and awareness in terms of its open-monitoring aspects

Variables – control vs experimental condition, participants (novice vs expert), clinical vs non-clinical, outcomes by bandwidth (alpha, beta, theta, delta and gamma), hemispheric asymmetry and event-related potential outcomes

A systematic review of the neurophysiology of mindfulness on EEG oscillations, Neuroscience and Biobehvioral Reviews 57 (2015) 401-410

fMRI Evidence for Mindfulness

Review of MRI studies involving mindfulness that enhance understanding of the neural processes associated with mindfulness meditation

Great variability in methods and populations studied do not allow for firm conclusions

Convincing evidence that mindfulness is associated with brain activation and/or connectivity of a number of regions:

Frontal cortex: lateral FC, Ventrolateral FC, Dorsolateral FC, Medial FC, Medial FC, Orbitofrontal cortex, Posterior medial cortex, Insula, Temporal Cortex, Temporoparietal junction, Sensorimotor cortex, Inferior parietal lobule, Parahippocampal gyrus. Amygdala, Basal Ganglia, Thalamus

Automatic thoughts associated with depression and anxiety and associated with the DMN, objective awareness of automatic thoughts (mindfulness) is a primary mechanism by which mindfulness decreases symptoms of depression, anxiety and stress

Neural mechanisms of mindfulness and meditation: Evidence from neuroimaging studies, World Journal of Radiology, 2014 July 28; 6(7): 471-479

Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia, J Neurosci., November 18, 2015 – 35(46)

Thank you for your mindful

attention!

Resources: Apple’s favourite app of 2017