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Aware Medicine: Self-Exploration, Self-Care, and Mindfulness in Residency Training Luke Fortney, MD Adam Rindfleisch, Aware Medicine: Self-Exploration, Self-Care, and Mindfulness in Residency Training Luke Fortney, MD Adam Rindfleisch, MD April 30, 2009

Today’s Format • Description of the Aware Medicine Curriculum – History – successes and…opportunities Today’s Format • Description of the Aware Medicine Curriculum – History – successes and…opportunities to learn – Outline of content – Health Research and Meditation • Experiential learning • Group discussions

 • The George Washington Institute for Spirituality and Health (GWish) • Established 2001 • The George Washington Institute for Spirituality and Health (GWish) • Established 2001 • Working toward “…a more compassionate system of healthcare by restoring the heart and humanity of medicine through research, education, and policy work focused on bringing increased attention to the spiritual needs of patients, families, and healthcare professionals. ” • Grants to create residency curricula in spirituality

Point to Ponder #1: What is spirituality? • University of Wisconsin has 16 residents Point to Ponder #1: What is spirituality? • University of Wisconsin has 16 residents in each of 3 classes – Different backgrounds • • Caution about ‘agenda-promoting’ Relevance for medical practice Not just about memorizing facts Relevance for one’s life, for challenges healers-in-training encounter

 • “Spirituality is a constellation of practices that awaken the heart and mind. • “Spirituality is a constellation of practices that awaken the heart and mind. ” -Roger Walsh

In other words… Let them define it! • Self exploration • The Healer’s Journey In other words… Let them define it! • Self exploration • The Healer’s Journey – “Compared to this direct realization of the sacred, mere book learning and theoretical knowledge are very poor substitutes, as far removed from direct experience as a text on human reproduction is from the embrace of a lover…” – Roger Walsh, MD

May help patients too… • In a study comparing placebo to imipramine for clinical May help patients too… • In a study comparing placebo to imipramine for clinical depression, it was found that a good physician had better results with a placebo than did a poor physician with the active drug. – Mc. Kay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. J Affect. Disord. 2006; 92: 287 -90.

One-third of the psychiatrists had better outcomes with placebo than onethird of the psychiatrists One-third of the psychiatrists had better outcomes with placebo than onethird of the psychiatrists had with imipramine. (Lower is better. )

 • The person of the physician makes a difference in the response to • The person of the physician makes a difference in the response to medication and placebo. – We as physicians are not only providers of a treatment, but we are also a means of treatment. • How do you teach something like that?

Point to Ponder #2: Tailoring to a residency curriculum • Residents are very busy Point to Ponder #2: Tailoring to a residency curriculum • Residents are very busy • Residents have many intense and challenging experiences • They are asked to do a lot already • So how can we make it easier?

Challenges • Face time with residents • Language • Buy-in • Bureaucratic issues • Challenges • Face time with residents • Language • Buy-in • Bureaucratic issues • Required versus elective • Resident-friendly approaches (less time, more value)

www. fammed. wisc. edu/aware-medicine Or Google “Aware Medicine” www. fammed. wisc. edu/aware-medicine Or Google “Aware Medicine”

Point to Ponder #3: What is useful to you? Point to Ponder #3: What is useful to you?

The Curriculum 1. Self-Awareness – – Self-care Setting Priorities Health Plans Preventing Burnout • The Curriculum 1. Self-Awareness – – Self-care Setting Priorities Health Plans Preventing Burnout • Ie, energizing! – Links and Resources “We don’t know what we don’t know. ” What happens around you?

The Curriculum 2. Awareness of Others – – – – Belief Systems Cultural Humility The Curriculum 2. Awareness of Others – – – – Belief Systems Cultural Humility Spirituality Ethics Epistemology Communication Compassion Case Archives "[People] may be said to resemble not the bricks of which a house is built, but the pieces of a picture puzzle, each differing in shape, but matching the rest, and thus bringing out the picture. " -Felix Adler

3. Mindfulness – – – Experiential component Meld into day-to-day experience Collaboration with University 3. Mindfulness – – – Experiential component Meld into day-to-day experience Collaboration with University of Wisconsin Mindfulness-Based Stress Reduction Program UW Research Park Clinic

What we ask of them • • • Create a health plan Case logs What we ask of them • • • Create a health plan Case logs Mindfulness experiences Meet with mentor Complete evaluations Minimum additional time commitment in 3 years: 10 hours *But they can do much more…

Meditation and Medicine • Big picture • Definitions and background • Evidence • Experiential Meditation and Medicine • Big picture • Definitions and background • Evidence • Experiential • Application

Meditation and Medicine • Medicine (Latin): mederi – to heal and look after • Meditation and Medicine • Medicine (Latin): mederi – to heal and look after • Meditation (Latin): meditari – to think about and consider

Meditation and Medicine • Medicine: the restoration of right inward measure when it is Meditation and Medicine • Medicine: the restoration of right inward measure when it is disturbed • Meditation: the direct perception of right inward measure - Jon Kabat-Zinn

Meditation and Medicine • Health is about balance – Dx: anxiety/stress, pain/suffering – Rx: Meditation and Medicine • Health is about balance – Dx: anxiety/stress, pain/suffering – Rx: clarity + equanimity = wellbeing

What is Mindfulness? • Mindfulness is… – – paying attention, on purpose, in the What is Mindfulness? • Mindfulness is… – – paying attention, on purpose, in the present moment, non-judgmentally • …Awareness

The Roots of Mindfulness • Mindfulness is an inherent human capacity that can be The Roots of Mindfulness • Mindfulness is an inherent human capacity that can be developed • Described and rediscovered in many traditions, works, places, and times • (Buddhism, Taoism, Yoga, Emerson, Thoreau, Whitman, Indigenous Culture…)

Research • Anxiety disorders (Kabat-Zinn et al. APA 1992) – MBSR reduces symptoms of Research • Anxiety disorders (Kabat-Zinn et al. APA 1992) – MBSR reduces symptoms of anxiety & panic, maintains reduction of symptoms

Research • Depression (Teasdale et al, J. of Consulting and Clinical Psychology, 2000, vol Research • Depression (Teasdale et al, J. of Consulting and Clinical Psychology, 2000, vol 68, no#4, 615 -623) – Significantly reduced risk of relapse/recurrence in recovered recurrently depressed patients

Research • Fibromyalgia (Kaplan et al. GHP 15, 284 -289, 1993) – 51% showed Research • Fibromyalgia (Kaplan et al. GHP 15, 284 -289, 1993) – 51% showed moderate to marked improvement of symptoms

Research • Chronic Pain (JKZ et al. J. Behavioral Med, vol 8, no#2, 1985) Research • Chronic Pain (JKZ et al. J. Behavioral Med, vol 8, no#2, 1985) – MBSR reduces self-reports of pain and pain related behaviors

Research • Well being (Reibel et al. General Hospital Psychiatry 23, 2001, 183 -192) Research • Well being (Reibel et al. General Hospital Psychiatry 23, 2001, 183 -192) – 8 week MBSR program enhances functional status, well being, reduces physical symptoms & psychological distress – Long term beneficial effects

The Psoriasis Study • 37 patients, randomized prospective study • UV light tx w/ The Psoriasis Study • 37 patients, randomized prospective study • UV light tx w/ or w/o MBSR tape • Psoriatic lesions assessed by – unblinded nurses – blinded physicians – blinded dermatologists Kabat-Zinn et al. Influence of MBSR Intervention on Rates of Skin Clearing in Patients with Moderate to Severe Psoriasis Undergoing Phototherapy and Photochemotherapy. 1998, Psychosom Med 60: 625 -632.

The Psoriasis Study • Significant difference b/w MBSR tape group & no-tape group at The Psoriasis Study • Significant difference b/w MBSR tape group & no-tape group at HP and CP • Rate of HP & CP 4 times faster in tape group Kabat-Zinn et al. Influence of MBSR Intervention on Rates of Skin Clearing in Patients with Moderate to Severe Psoriasis Undergoing Phototherapy and Photochemotherapy. 1998, Psychosom Med 60: 625 -632.

Gamma wave synchronization • Longtime practitioners show organized brain activation on scale never seen Gamma wave synchronization • Longtime practitioners show organized brain activation on scale never seen before – High-frequency gamma wave synchronization especially intense in the left prefrontal cortex • Gamma waves associated with attention and mood Lutz et al. Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. PNAS 2004

Gray matter protection • Effect of mindfulness practice on the brain – 13 regular Gray matter protection • Effect of mindfulness practice on the brain – 13 regular Zen meditation practioners – 13 controls – MRI mapping of CNS gray matter Pagoni G, Cekic M. Age effects on gray matter volume and attentional performance in Zen meditation. Neurbio Aging. 2007, 28; 1623 -27.

Gray matter protection • Age related gray vol loss in controls • No gray Gray matter protection • Age related gray vol loss in controls • No gray matter loss in meditators • Particular increase in the putamen – cognitive flexibility and attention Pagoni G, Cekic M. Age effects on gray matter volume and attentional performance in Zen meditation. Neurbio Aging. 2007, 28; 1623 -27.

Promega Study • Methods – 48 right handed subjects employees of Promega in Fitchburg, Promega Study • Methods – 48 right handed subjects employees of Promega in Fitchburg, WI. – Subjects randomized into Meditation group (N=25, 19 females) and a wait-list control group (N=16, 10 females). 3: 2 ratio. – Mean age 36 years (range 23 -56 yoa). – Wait-list controls were provided 8 -wk MBSR training program after completion of study.

Promega study • Meditation practice increases left PFC – ↓ anxiety & negative affect Promega study • Meditation practice increases left PFC – ↓ anxiety & negative affect – ↑ positive affect – ↑ immunity Davidson et al. Alterations in Brain and Immune Function Produced by Mindfulness Meditation. 2003, Psychsom Med.

Right vs Left PFC activation Negative ---- Positive Right vs Left PFC activation Negative ---- Positive

Mindfulness and patient care • RCT, double blinded • 18 week study • 18 Mindfulness and patient care • RCT, double blinded • 18 week study • 18 interns (9 controls) • 124 inpatients • Active arm taught daily Zen meditation • SCL-90 and patient impact scores Ludwig et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients. Psychother and psychosom. 2007; 76: 332 -338

Mindfulness and patient care • MED group with > symptom reduction • Teaching mindfulness Mindfulness and patient care • MED group with > symptom reduction • Teaching mindfulness to residents positively influences patient care Ludwig et al. Promoting mindfulness in psychotherapists in training influences the treatment results of their patients. Psychother and psychosom. 2007; 76: 332 -338

Yes, And… Yes, And…

Practice the ingredients • Meditation in a nutshell – T: – I: – E: Practice the ingredients • Meditation in a nutshell – T: – I: – E: – S: mental Talk/Thoughts mental Images Emotional feelings physical Sensations

Practice the recipe • Meditation in a nutshell – Stop (take pause) – Observe Practice the recipe • Meditation in a nutshell – Stop (take pause) – Observe it (acknowledge it) – Let it be (non-striving) – Return to your anchor (just breathe)

Challenges to being mindful • • • Misconceptions Overstretched Too much too soon Try Challenges to being mindful • • • Misconceptions Overstretched Too much too soon Try too hard Tx for our patients Insufficient evidence Give up too early No support Fear of subjectivity No reason or purpose

Suggestions for practice • Listen with your whole body • Deep breath before each Suggestions for practice • Listen with your whole body • Deep breath before each patient • Stethoscope listening • Call room/office centering • Daily practice* • Supportive group *Pradhan E, Baumgarten M et al. Effect of MBSR in Rheumatoid Arthritis Patients. Arthr Rheum Vol 57, No 7, Oct 15, 2007, pp 1134 -1142.

Thank you Adam Rindfleisch MD (adam. rindfleisch@fammed. wisc. edu) Luke Fortney MD (luke. fortney@fammed. Thank you Adam Rindfleisch MD (adam. [email protected] wisc. edu) Luke Fortney MD (luke. [email protected] wisc. edu)