Should anaesthetists be mindful? | Association of Anaesthetists
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Should anaesthetists be mindful?

Box 1

WHO defines burn-out as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

  • feelings of energy depletion or exhaustion 
  • increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job 
  • reduced professional efficacy

Box 2

Some practical tips:

  • Focus on the point where you feel your breath most and observe your body’s sensations and your emotions without judgment, before or during a stressful time 
  • During any form of exercise, bring your attention to your body’s sensations 
  • Download a meditation app (many free apps are available)
  • Consider joining a MBSR course

A mindful sea view

Thoughts are not FACTS

Should anaesthetists be mindful?

One of the authors (UD) joined a Mindfulness-Based Stress Reduction (MBSR) course 10 years ago, following the recommendation of one of his patients who found MBSR helped her with bowel symptoms and stress. Since then, he has been practising meditation and attended teacher training retreats at Bangor University, and has been running ‘debrief and wellbeing’ weekly sessions for hospital staff during COVID-19, which include supportive conversation and group meditation. Admitting vulnerabilities and sharing stories of kindness has helped the group deal with this crisis.

Mental health and wellbeing are attracting increasing recognition in the medical community. Eighty per cent of doctors in a recent BMA survey were at high or very high risk of burnout, with junior doctors being most at risk (Box 1). Forty per cent of respondents reported suffering currently from a broader range of psychological and emotional conditions [1]. Anaesthetists in training show similar results, with 85% at high risk of burnout [2]. The current situation with COVID-19 adds new layers of personal apprehension and uncertainty. A recently published review article states that doctors are most likely to become mentally ill when they feel isolated or unable to do their job [3].

Mindfulness is the psychological process of purposely bringing one's attention to experiences occurring in the present moment without judgment

Dobkin et al. showed significant reductions in stress and burnout, and increases in mindfulness, following MBSR training [4]. The decrease in emotional exhaustion was correlated with more ‘acting with awareness’ and less ‘judgmental attitudes’, which are both facets of mindfulness. Patients' perceptions of clinical encounters suggest that patient-centred care improved after MBSR [4]. While a large number of studies show significant improvements in wellbeing and performance of doctors and other healthcare professionals following MBSR, many of these are of low quality. A systematic review concluded that mindfulness could have a positive impact on health professionals' ability to deal with stress, but methodological limitations of the training were also highlighted [5]. The role of mindfulness in addressing healthcare workers’ burnout is also promising. After several weeks of meditation-based techniques, 23 of 34 studies reported an improvement on measured burnout [6].

Meditation has proven difficult to define as it covers a wide range of dissimilar practices in different traditions. Walsh and Shapiro refer to meditation as: 'a family of self-regulation practices that focus on training attention and awareness in order to bring mental processes under greater voluntary control and thereby foster general mental well-being and development and/or specific capacities such as calm, clarity, and concentration’ [7]. 

Mindfulness is the psychological process of purposely bringing one's attention to experiences occurring in the present moment without judgment, which one develops through the practice of meditation and other training.

There are limited cohesive, overarching attempts to describe the various psychobiological processes that meditation sets in motion, and the scientific basis of its effect. 

MBSR is an 8-week evidence-based programme that offers secular, intensive mindfulness training. It is a practical approach that trains attention, allowing people to cultivate awareness and thereby enabling them to have more choice to take wise action in their lives. Developed at the University of Massachusetts Medical Center in the 1970s by Professor Jon Kabat-Zinn, MBSR uses a combination of mindfulness meditation, body awareness, yoga, exploration of patterns of behaviour, thinking, feeling and action. The MBSR programme is a workshop taught by certified trainers that entails weekly group meetings (2.5 h classes), a one-day retreat with seven hours of mindfulness practice between sessions #6 and #7, homework of 45 min daily, and instruction in three formal techniques: mindfulness meditation; body scanning; and simple yoga postures [8].

There are limited cohesive, overarching attempts to describe the various psychobiological processes that meditation sets in motion, and the scientific basis of its effect. A review by Carol Reive, including studies looking at psychobiological aspects of MBSR, demonstrated that the prefrontal cortex, responsible for integration and cognition, exhibits decreased connectivity with the amygdala [9]. The amygdala are responsible for the ‘fight or flight’ stress response, and possibly their reactivity is tempered through learned, non-judgmental, in-the-moment awareness. The studies evaluated supported the premise that MBSR can decrease systolic and diastolic blood pressure, but did not demonstrate an effect on heart rate variability or respiratory measures. The literature on MBSR shows preliminary support for a reduction in cortisol, CRP, decreased natural killer cell activity, decreased NF-kB (a protein complex that controls transcription of DNA), and increased or buffered declines of CD4 + T cell counts (Th1 and Th2) that facilitate a return to allostasis. By practicing MBSR techniques, improvements can be seen in the brain regions responsible for perception, memory and response flexibility, which translate to decreased stress reactivity. This modified reaction by the brain appears to influence the body's stress response, resulting in improvements of the autonomic, immune, inflammatory and endocrine systems [9].

Mindfulness has the potential to support wellbeing in healthcare professionals, but individuals and providers need to be aware of the downsides. MBSR is demanding in terms of individual commitment and organisational resources. Currently, there is no professional or statutory registration required to teach mindfulnessbased interventions such as MBSR and Mindfulness-Based Cognitive Therapy, and no regulatory body that oversees the training of mindfulness teachers. Further, qualitative research on mindfulness meditation shows that it may increase the awareness of difficult feelings and exacerbate psychological problems [10]. We must therefore understand for whom and under what circumstances it works, and when it may be contraindicated.

The Association of Anaesthetists summarises the role of mindfulness well: 'Mindfulness won't make your problems disappear, but it will help you break patterns of unhelpful behaviour such as being self-critical or not prioritising your own wellbeing. It will help you to stop wanting things to be different and instead help you accept things the way they are. Being mindful allows you to better observe patients’ responses while remaining focused and aware of tasks and surroundings. It decreases errors and improves patient safety. It gives you space to ‘be’ and will help you respond to stressful situations more calmly and with less anxiety ’ (Box 2) [11].

Umakant Dave
Consultant Gastroenterologist & Honorary Senior Lecturer
Morriston Hospital, Swansea

Professor Andrew Grant
Professor of Clinical Education
Swansea University Medical School

Twitter: @swanseadave; @ajgrant_andy

References 

  1. British Medical Association. Caring for the mental health of the medical workforce, 2019. https://www.bma.org.uk/media/1365/bma-caring-for-the-mental-healthsurvey- oct-2019.pdf (accessed 1/9/2020). 
  2. Royal College of Anaesthetists. A report on the welfare, morale and experiences of anaesthetists in training: the need to listen, 2017. https://www.rcoa.ac.uk/sites/ default/files/documents/2019-08/Welfare-Morale2017.pdf (accessed 1/9/2020). 
  3. Carrieri D, Mattick K, Pearson M, et al. Optimising strategies to address mental ill-health in doctors and medical students: ‘Care Under Pressure’ realist review and implementation guidance. BMC Medicine 2020; 18: 1-10. 
  4. Dobkin PL, Bernardi NF, Bagnis CI. Enhancing clinicians' well-being and patientcentered care through mindfulness. Journal of Continuing Education in the Health Professions 2016; 36: 11-16. 
  5. Lomas T, Medina JC, Ivtzan I, Rupprecht S, Eiroa-Orosa FJ. A systematic review of the impact of mindfulness on the well-being of healthcare professionals. Journal of Clinical Psychology 2018; 74: 319-55. 
  6. Anaelle K, Taieb O, Xavier S, Baubet T Reyre A. The benefits of mindfulness-based interventions on burnout among health professionals: a systematic review. Explore 2019; 16: 35-43. 
  7. Walsh R, Shapiro SL. The meeting of meditative disciplines and Western psychology: a mutually enriching dialogue. American Psychologist 2006: 61: 227- 39. 
  8. Lamothe M, Rondeau É, Malboeuf-Hurtubise C, Duval M, Sultan S. Outcomes of MBSR or MBSR-based interventions in health care providers: a systematic review with a focus on empathy and emotional competencies. Complementary Therapies in Medicine 2016; 24: 19-28. 
  9. Reive C. The biological measurements of Mindfulness-Based Stress Reduction: a systematic review. Explore 2019; 15: 295-307. 
  10. Lomas T, Cartwright T, Edginton T, Ridge D. A qualitative analysis of experiential challenges associated with meditation practice. Mindfulness 2015; 6: 848–60. 
  11. Association of Anaesthetists. Using mindfulness, 2020. https://anaesthetists. org/Home/Wellbeing-support/Mental-wellbeing/Using-mindfulness (accessed 1/9/2020).

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