Mindfulness, your patients, and you

Mindfulness has been studied and supported as an adjuvant therapeutic intervention for a number of chronic medical conditions commonly seen in the primary care setting. The term refers to a quality of awareness that is cultivated through meditation training as a way to pay more careful, non-judgmental attention to the here-and-now.

Jon Kabat-Zinn, PhD, who introduced mindfulness-based stress reduction in 1971 at the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School, describes it in terms of an awareness that arises by paying attention on purpose, in the present moment, in the service of wisdom and compassion.

It has since been offered as a potential intervention for chronic pain, depression, and anxiety, among other conditions. But in addition to helping patients better manage chronic, difficult-to-treat conditions, it could also have benefits for physicians themselves. Practicing mindfulness in their own lives could be a path to managing job stress and burnout.

The term mindfulness could benefit from some demystification, says Michael Krasner, MD, professor of clinical medicine at the University of Rochester, N.Y., School of Medicine and Dentistry. Krasner has taught mindfulness-based stress reduction to practicing physicians at Rochester for nearly 20 years and has written about the program’s benefits for physician well-being and for patient-centered care in JAMA. “There has been a certain amount of commodification of the term in recent years. What we’re essentially talking about are the important qualities for being a good physician-to be an awake, aware, involved human being,” he explains.

“Most of us as physicians could benefit from a little more awareness, and we can utilize that awareness with our patients who have chronic illnesses to help them develop a better sense of self-awareness and take better care of themselves,” Krasner says. With some education and practice, doctors can cultivate those qualities, which can enhance the quality of their own lives and their own well-being.

Research data connects physicians’ well-being with the quality of the care they deliver, he says. What’s more, successful applications of mindfulness techniques by patients could increase their satisfaction with their medical care, as expressed in quality and customer satisfaction surveys. This is particularly important with chronic conditions for which there is no easy or permanent fix, for which dissatisfaction rates could be high.

Best evidence for mindfulness benefits

The areas with the strongest evidence for the benefits of mindfulness training for patients include preventing relapse from major depressive disorders, addressing anxiety, especially for patients who don’t want to take medications, and managing chronic pain, which is now a hot-button topic across the health care system. A Spanish study found that mindfulness meditation training reduced clinically measured blood pressure in patients with high-normal BP or grade 1 hypertension. Other research suggests it may have benefits for migraine as part of a stress-reducing lifestyle and as part of therapy for patients with post-traumatic stress disorder.

“There’s a lot of evidence for these chronic conditions-certainly as much as for pharmaceuticals,” says Anthony Back, MD, co-director of the Center for Excellence in Palliative Care at the University of Washington and cofounder of Vital Talk, which teaches clinicians communication skills for use with serious illnesses.

In the United Kingdom, the National Health Service calls mindfulness-based cognitive therapy a preferred therapy for preventing relapse after recurrent major depressive disorder, and it has been demonstrated to be as powerful as medications in decreasing incidence of relapse. And a mindfulness-based program focused on chronic pain management has been shown to improve pain patients’ quality of life, Krasner says. “Their actual pain scores didn’t change, but they were better able to adapt to the pain.”

But if physicians are going to suggest mindfulness training to their patients as a way of better managing certain chronic conditions, Back recommends getting to know first-hand how it really works and meeting the teachers of mindfulness practice in their community. By taking a mindfulness course as an individual, the doctor can get a better sense of how it might be received by patients. Not everyone will be open to a suggestion of pursuing mindfulness training, Back adds. But with the right teacher it can help many patients.

Mindfulness classes are taught today in most communities, although coverage for them in health insurance benefits is variable. The physician’s challenge, he adds, is to understand that mindfulness is not a medical treatment in the traditional sense. Instead, it means starting on a path toward behavioral change, retraining the brain to better deal with challenges such as chronic pain.

“It’s not that we’re going to eradicate your pain-but we can help you do things that matter in order to live a more functional life,” Back says. “We have conditioned people to think there’s a pill for everything, and so physicians have to explain why chronic conditions like pain need to be managed differently.”

Chronic burnout

There is a fair amount of evidence that a mindfulness practice can also help physicians proactively avoid job stress-related burnout, Back says. “By itself it may not be a magic bullet. But it’s one of the skills doctors can bring to bear in a stressful work environment.” And in this way, they can restore some balance to their work day and reconnect with what drew them to the profession in the first place.

Burnout is a chronic disease that is crippling the medical profession, says Gail Gazelle, MD, assistant professor of medicine at Harvard Medical School and a physician coach in job stress management, burnout prevention, leadership, and wellness. “Mindfulness can help with these issues by generating calm, refocusing on what is going well and tuning out distractions,” she says.

A lot of physicians today say they feel like they are imposters, an attitude which can be inculcated by the rigors of medical training, Gazelle says. Mindfulness training encourages doctors to pay attention to the present moment, with less of the self-judgment that is sometimes brought to these interactions.

The mind is a very busy place, Gazelle says. “Yet you can learn to quiet your mind. Doctors sometimes say they can’t meditate because their mind is too busy-but in mindfulness training, you’re working with the mind as it is. Meditation helps us repetitively shift our thoughts back to our breath-strengthening that muscle. But it takes training and finding the time to sustain the practice.”

Mindfulness classes teach such techniques as using a meditative anchor, for example, observing one’s breath; adopting an appropriate meditation posture; experiencing routine tasks as if for the first time; and trying to integrate mindfulness into everyday life. When seeing the next patient, the doctor can stop at the doorknob and take a deep breath to be present before entering the room. A number of mindfulness apps are available online, Gazelle says, such as the Headspace App for guided meditation; Calm; and 10% Happier.