Can Mindfulness Save Primary Care?
Abstract & Commentary
By Craig Schneider, MD. Dr. Schneider is Director of Integrative Medicine, Department of Family Medicine, Maine Medical Center, Portland, ME; he reports no financial relationship to this field of study.
Synopsis: This single-group cohort before-and-after study of an intensive educational program for primary care physicians focusing on mindful communication and self-awareness demonstrated improvements in physician well-being and attitudes toward patient- centered care.
Source: Krasner MS, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302: 1284-1293.
The purpose of this study was to determine if an educational program designed to improve primary care physician (PCP) mindfulness, communication, and self-awareness could subsequently improve their sense of well-being and reduce psychological distress and burnout while increasing ability to relate to their patients. All PCPs (family medicine, general internal medicine, pediatrics, or combined internal medicine and pediatrics) in active practice in one northeastern United States metropolitan area were invited to participate. Seventy of 871 volunteered to participate. The program was free; CME and a stipend were provided for participation and completion of surveys.
The program consisted of an initial intensive phase (eight weekly 2.5-hour sessions, and one 7-hour session) and then a maintenance phase of 10 monthly 2.5-hour sessions. Each session had a brief didactic component exploring the weekly theme (i.e., managing conflict, preventing burnout, etc.), followed by Mindfulness Meditation consisting of a body scan (attending to physical, cognitive, and emotional sensations without attempting to change them), sitting meditation (awareness of thoughts), walking meditation (awareness of experience), or mindful movement (such as yoga). Narrative and appreciative inquiry exercises such as writ-ing brief stories of personal experience and sharing these in small groups were used to foster awareness of self, relationships, and communication.
Subjects completed five sets of surveys: at registration ~5 weeks prior to first session, first session, conclusion of intensive phase (8-week survey), at final session (10-month survey), and the final survey 3 months after the program's conclusion (15-month survey). The survey set comprised multiple measures including the 2-Factor Mindfulness Scale, Maslach Burnout Inventory, Jefferson Scale of Physician Empathy, Physician Belief Scale, and the Mini-markers of the Big Five Factor Structure personality scale, as well as the Profile of Mood States (POMS). Of the 70 PCPs enrolled, 60 (86%) completed survey 1, 68 (97%) survey 2, 59 (84%) survey 3, 56 (80%) survey 4, and 51 (73%) survey 5. They attended an average of 33 hours of the 52-hour program.
At the end of the intervention, mindfulness scores demonstrated the largest effect sizes (1.12 total mindfulness; 95% confidence interval [CI], 0.86-1.38; P < 0.001). Maslach Burnout Inventory improved across all subscales and most significantly for personal accomplishment (effect size 0.44; 95% CI, 0.19-0.68; P < 0.001) and total empathy (effect size 0.45; 95% CI, 0.24-0.66; P < 0.001). The physician belief scale improvements suggested a shift toward a more psychosocial and less disease-oriented approach (effect size, 0.37; 95% CI, 0.14-0.59; P = 0.001). The POMS demonstrated moderate effect sizes in total (0.69; 95% CI, 0.43-0.95; P < 0.001), and subscales of depression (0.55; 95% CI, 0.29-0.81; P < 0.001), anger (0.76; 95% CI, 0.48-1.05; P < 0.001), and fatigue (0.81; 95% CI, 0.51-1.11; P < 0.001). Improvements in mindfulness correlated moderately with decreases in total mood disturbance (r = -0.39; P < 0.001) and emotional exhaustion subscale of burnout (r = -0.32; P < 0.001), and increases in perspective taking subscale of physician empathy (r = 0.31; P < 0.001).
The authors concluded that PCPs participating in a CME program designed to improve mindful communication demonstrated improvements in measures of well-being and personal characteristics associated with clinical care that is more patient-centered over the 15-month trial and follow-up.
Commentary
By now we all know the U.S. health system spends a higher portion of its gross domestic product on health care than any other country yet ranks 37th out of 191 countries in performance, according to the World Health Report.1 As President Obama and Congress attempt to reform health care and health care coverage to provide affordable and high-quality care, they must keep in mind that the success of these reforms depends on ensuring an adequate supply of primary care physicians to provide that care. "The importance of primary care is based on decades of research demonstrating its role in producing improved outcomes at lower costs."2 Yet despite research demonstrating that a strong primary care infrastructure leads to improved health outcomes, graduates of U.S. medical schools are not choosing to specialize in primary care.3 Reasons for this include "increasing indebtedness for medical trainees, the ever-widening gap in salaries between primary care and specialist physicians, an exponential increase in primary care functions, and burnout among practicing physicians called on to deliver more and more services in less and less time."4 Such pervasive burnout among physicians is well documented in the literature,5 with burnout characterized as loss of enthusiasm for work (emotional exhaustion), objectification of people (depersonalization), and the loss of a sense of meaning in work (low personal accomplishment).6 Thus, any effective strategies for decreasing burnout would be critical to attracting and retaining a high-quality primary care infrastructure.
In this article, Krasner et al provide intriguing evidence that an educational program designed to improve PCP mindfulness, self-awareness, and communication may be such a strategy. Their intervention appears to improve physician sense of well-being, psychological distress, and burnout, while increasing empathy toward patients. It is exciting that most of these changes were reported to be detectable early and sustained for the full 15 months. The authors acknowledge many of the limitations of this study including the fact that it was a single-group cohort study rather than a randomized controlled trial. Participants were self-selected, more likely to be family physicians, and less likely to practice in rural areas and thus may not be representative of a general PCP population. Because there was no control group, simply the fact the PCPs spent time on a regular basis with colleagues may be a significant confounder. Interestingly, on average at baseline these volunteers were nearly but not quite "burned out." Furthermore, due to the nature of multi-component interventions (i.e., didactic material, formal mindfulness meditation, narrative and appreciative inquiry exercises, discussion, etc.), it is difficult to determine which component, or combination of components, is related to the improvements seen unless the groups receiving each type of intervention are appropriately separated. Had Krasner et al used this method then we would have a much better understanding of which intervention strategy had the most significant influence on the outcome. Finally, it would have been particularly interesting had they examined potential differences between physicians who completed all of the sessions (this number was not reported) and those who attended at least 1 session (68 participants).
Despite these limitations, Krasner et al have contributed an important clue to the puzzle of how to improve recruitment and retention of primary care physicians by reducing burnout and promoting wellness through mindful practice without which no meaningful reformation or improvement of American health care is likely. Next steps should include attempts to reproduce this work in a more representative population of PCPs that includes a control group, methodology to parse out most important aspects of the intervention, and outcomes in clinical care as well as patient perceptions.
References
1. The World Health Report 2000 - Health systems: Improving performance. Geneva, Switzerland: World Health Organization; 2000.
2. Starfield B, et al. Contribution of primary care to health systems and health. Milbank Q 2005; 83:457-502.
3. Campos-Outcalt D, et al. A comparison of primary care graduates from schools with increasing production of family physicians to those from schools with decreasing production. Fam Med 2004;36:260-264.
4. Lee TH, et al. Perspective roundtable: Redesigning primary care. N Engl J Med 2008;359:e24.
5. Shanafelt T, et al. The well-being of physicians. Am J Med 2003;114:513-517.
6. Maslach C, et al. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
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