Mindfulness training?

Here are a few important facts.  Health care workers were suffering from burnout even before the COVID-19 pandemic.  Some studies suggested that close to half of all physicians in the United States met the criteria for at least one of the three dimensions (emotional exhaustion, depersonalization, and loss of sense of personal accomplishment) of burnout in the Maslach Burnout Inventory.  The percentage is even higher for physicians in training (residents and fellows).  However, burnout is not limited to physicians - more than one-third of nurses in the U.S. met these same criteria.  After nearly two years of a global pandemic, physician burnout has become even worse, with a recent survey in Medscape reporting burnout affected more than 2/3 of the nearly 7,500 physicians completing the survey.

The increased awareness on the issue of widespread burnout among health care workers is a necessary step in the right direction.  Just as important are the growing number of studies that seek to address this issue (see for example, a systematic review and meta analysis published in the journal Lancet in 2016).  Tait Shanafelt, the Chief Wellness Officer at Stanford Medicine and one of the world's leading authorities on physician burnout proposed nine organizational strategies to address burnout in health care today:

1. Acknowledge and assess the problem
2. Harness the power of leadership
3. Develop and implement targeted interventions
4. Cultivate community at work
5. Use rewards and incentives wisely
6. Align values and strengthen culture
7. Promote flexibility and work-life integration
8. Provide resources to promote resilience and self-care
9. Facilitate and fund organizational science

I want to draw particular attention to organizational strategy #8, particularly as concepts such as mindfulness, self-care, and resilience have received a lot of negative attention lately (see my own post from last year, "Don't ask me to to take resilience training!").  I fully recognize that as a physician executive, I advocate self-care, mindfulness, and resilience at my own peril - they are very, very unpopular (perhaps because some health care organizations have required education and training focused on these aspects without doing anything else to address burnout).

Here's the important point, though.  Even if physicians are already more resilient (as a group) compared to the general population, strategies to promote resilience and self-care can still be effective.  Recall that in Maslow's Hierarchy of Needs, individuals must meet their most basic needs (primarily physiologic needs, such as the need for food, water, and rest, but also the need for both physical and psychological safety) first.  Self-care is important, but organizations absolutely must provide the necessary support and resources so that physicians can meet their basic needs - providing breaks for meals (breakfast, lunch, or dinner) and access to water during the work shift; providing the necessary tools (e.g. patient lifts, personal protective equipment, etc) to prevent injuries while at work; limiting the duration of the work shift and providing sufficient recovery time for rest between shifts; and establishing a culture of psychological safety.  

Perhaps it's a surprise that there is a growing body of evidence suggesting that things like mindfulness and resilience training can be effective at relieving the stress of burnout.  Mindfulness training teaches techniques such as meditation, breathing, and guided imagery to relax the body and mind and reduce stress.  Mindfulness training is currently the only evidence-based approach to reduce burnout in the Accreditation Council for Graduate Medical Education and American Academy of Pediatrics call for system-level change to address burnout in physicians in training.  

Of interest, a group of investigators recently conducted a multicenter cluster randomized clinical trial at 15 pediatric residency training programs in the United States.  The sudy subjects, a group of 340 pediatric interns (first year out of medical school) were randomized to the intervention (mindfulness training) or control.  The mindfulness training consisted of seven monthly one-hour sessions, while the control arm consisted of seven monthly one-hour social lunches.

The primary outcome of the study was the emotional exhaustion dimension (EE) as measured by the Maslach Burnout Inventory.  Secondary outcomes, including mindfulness and empathy were measured using a standardized and widely accepted tool.  EE scores significantly increased at both 6 months and 15 months in both the intervention and control arms of the study (which is not surprising, given what we know about burnout in physicians in training).  However, the increase in EE scores was not different between the intervention and control groups.  Moreover, none of the secondary outcome measures (depersonalization dimension, personal accomplishment dimension, burnout, empathy, or mindfulness) differed between the two groups.

So, unlike previous studies, mindfulness training did not seem to make a difference in this study of first-year pediatric residents.  There are a number of important differences between this study and previous studies.  First, the mindfulness curriculum was not facilitated by an experienced mindfulness practitioner.  Second, previous studies have been relatively more intensive, in terms of the number of hours of training provided.  Third, and perhaps most importantly, participation in the mindfulness training was not required.  Conceivably then, one could just as easily argue that the training was insufficient to improve mindfulness (and notably, mindfulness scores were not different between the two groups).  

To these study limitations, I would also add one more caveat.  As I discussed above (and as proposed by Dr. Shanafelt), addressing burnout likely will require a multi-step approach that addresses factors at the personal (mindfulness, work-life integration, resilience, self-care), team (resources, leadership), and organizational (culture, leadership) levels.  I am actually not too surprised that an intervention focusing on just one of the nine strategies listed above failed to relieve burnout.

Clearly we have more work to do.  Burnout is an important issue for health care leaders.  And we need evidence-based strategies and tools to address this growing (and unfortunately, worsening) epidemic.