Spinning Plates:The art of professionalism in modern

medicine

Summer InstituteJuly 2014

University of OklahomaSchool of Community Medicine

How do we develop?What is systems-based practice?

What is a humanistic professional?

Jennifer K. Clark, MD

LOVEPLAY

…that together they create one cohesive narrative.(E. Erickson)

WORK

Self

We are most fulfilled when the basic outer expressions of ourselves—Work, Play, and Love—are developed in such a way….

Self: To identify and cultivate….

Your Why

Self

OK….

but what does this have to do with

Professionalism in Medicine??

Work: The struggle…

Shifting context of medical practice• Artisan/Vocational to Humanistic Professional

The concept of professionalism as an expression of teachable behaviors rather than character trait or virtue.• What then is the expectation of having basic core

values to enter the profession?

Practice and teaching professionalism…• The lynchpin of the hidden curriculum

Professionalism Framework

4 CORE VALUES

Integrity

Respect

Compassion

Social Justice and Excellence in Care

2 DOMAINS Individual

interactions• With patients/families• With colleagues

Organizational behaviors• Healthcare settings• Advocacy and

professional organizations

Lesser et al., JAMA, 2010

“One way of defining the character of clinicians is to examine their moment-to-moment actions…These small actions, cumulatively, describe the clinician as a practitioner and moral agent”

-Ron Epstein, MD

Professionalism: it’s a relational thing

Community & Regulatory

Organization Team Patient

Professionalism: Behavioral skills developed from core values that are demonstrated in the interactions between professionals as well as between professionals and organizations.

Crucial conversations and confrontations: the demonstrable acts professionalism:Self-Community & Regulatory Self-OrganizationSelf-TeamSelf-Patient Self-Personhood 

Advocacy: the intersect of work, play, and love

Self

Be All that You Can Be….

Practicing Professionalism

Self: To identify and cultivate….

ADAPTIVE CAPACITY

Self-awareness

Interpersonal skills

Intention of healing

-Lesser et al-Epstein et al

Self relative to Others

• Recognize it’s an everyday thing• Self-reflect….explicitly• Offer your narratives• Practice mindfulness• Expose the hidden curriculum• Demonstrate intolerance to

unprofessionalism

Self relative to Organization

As members of organizations, reflect on your current environments…

• Are you engendering a system where you or others are forced to be unprofessional?

What Do You Do When the Stuff Hits the Fan?Mindfulness as Self-Care for the Carer

Steve Hoppes, Ph.D.

What is mindfulness?“Mindfulness means moment-

to-moment nonjudgmental awareness.”

Jon Kabat-Zinn (2011, p. 231)

“Mindfulness is the energy that helps you be fully present with whatever is there.”

Thich Nhat Hanh (2002, p. 51)

Therapeutic effects of mindfulness meditation

Effective in reducing anxiety, depression, panic symptoms, mood disturbances, chronic pain, and stress. (Brown & Ryan, 2003; Kabat-Zinn et al., 1992; Minor et al., 2006; Teasdale, et al., 2000)

Reductions were maintained in 3-month & 3-year follow-ups. (Kabat-Zinn et al., 1992; Miller et al, 1995.)

Therapeutic effects, continued Mindfulness training resulted in improved

immune function, even in patients with HIV. (Siegel, 2011)

Mindfulness training resulted in enhanced self-compassion. (Germer & Neff, 2013).

Mindfulness has been shown to be effective in treating conditions such as obsessive-compulsive disorder, borderline personality disorder, and drug addiction. (Witkiewitz & Bowen, 2010; Siegel, 2011)

Richard Davidson on neuroplasticity

“ … meditation can produce increases in relative left-sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect.” (Davidson, et al., 2003)

http://www.youtube.com/watch?v=gJ1_Bmx7QdY&feature=related

Mindfulness & Medical Education(Rosenzweigh, Reibel, Greeson, & Brainard , 2003)

302 Jefferson Medical College students. Over 10 weeks, students trained in

mindfulness experienced decreased Total Mood Disturbances (TMD) (p=0.05), including Decreased anxiety (p=0.009), confusion

(p=0.009), and depression (p=0.09), while increasing vigor (p=0.006).

• Control group: Increased TMD (p<0.0001), anxiety (p<0.0001), confusion (p=0.02),, and depression (p =

0.06), while vigor (p<0.0001) decreased.

Physicians & Mindfulness In a study of 30 primary care physicians,

brief mindfulness training was associated with reductions in indicators of job burnout, depression, anxiety, and stress (Fortney et al., 2013).

Mindfulness leads to … Presence

• “Our true home is not in the past. Our true home is not in the future. Our true home is in the here and now.” Thich Nhat Hanh

Equanimity Open-heartedness Connectedness

• “We are here to awaken from our illusion of separateness.” Thich Nhat Hanh

Ram Dass "I help people as a

way to work on myself, and I work on myself to help people."

References Brown, K.W., & Ryan, R.M. (2003).  The benefits of being present: 

Mindfulness and its role in psychological well-being.  Journal of personality and social psychology, 84, 822-848.

Hanh, T.N. (2002). Be free where you are. Berkeley, CA: Parallax Press.

Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M. A., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K., & Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570.

Fortney, L., et al. (2013). Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. Annals of Family Medicine, 11, 412-420.

Germer, C. K., & Neff, K. D. (2013). Self‐compassion in clinical practice. Journal Of Clinical Psychology, 69(8),

Kabat-Zinn, J. (2005). Coming to our senses. NY: Hyperion.

References, continued Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G.,

Fletcher, K.E., Pbert, L., Lenderking, W.R., & Santorelli, S.F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–43.

Miller, J.J., Fletcher, K.E., and Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17,192–200.

Rosenzweig, Reibel, Greeson, Brainard, & Hojat. (2003). Mindfulness based stress reduction lowers psychological distress in medical students. Teaching & Learning in Medicine, 15, 88-92.

References, continued Siegel, D. (2011). The proven benefits of

mindfulness. In B. Boyce (Ed.), The Mindfulness Revolution, pp. 136-139, Boston: Shambhala.

Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness based cognitive therapy.  Journal of Consulting and Clinical Psychology, 68, 615-623.

Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78, 362-374.