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 .
Anaesthetists in training show similar results, with 85% at high
risk of burnout . 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 .
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
. 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 . 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 . 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
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’
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 .
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 . 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 .
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
. 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 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) .
Consultant Gastroenterologist & Honorary Senior Lecturer
Morriston Hospital, Swansea
Professor Andrew Grant
Professor of Clinical Education
Swansea University Medical School
Twitter: @swanseadave; @ajgrant_andy
- British Medical Association. Caring for the mental health of the medical workforce,
oct-2019.pdf (accessed 1/9/2020).
- 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).
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- Association of Anaesthetists. Using mindfulness, 2020. https://anaesthetists.