Wednesday, November 4, 2020

INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center

 

INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center.

Historically, surgeons deemed themselves highly resilient and resistant to the effects of stress. Over the past decade, it has steadily been recognized that surgeons are very susceptible to the effects of fatigue including burnout. Fortunately, I have had the pleasure of discussing this concern with several surgeons who are experts in the field of burnout, resiliency and mindfulness.

Following our collaborative efforts during the 2017 ACS panel, Crisis Management in the Operating Room, Dr. Sharmila Dissanaike, MD* (Chair Dept Surgery at TTUHSC), met with me to discuss her work in mindfulness training and its importance in developing resilience to burnout. She explained to me that she had positive experiences with teaching mindfulness and helping trainees develop more secure emotional intelligence.

After a Duke University Feagin Leadership Conference, I met with LTG (Ret) Eric B. Schoomaker, MD** (Surgeon General of the US Army 2007 to 2011) to discuss his thoughts about resiliency and the benefits of mindfulness training during his tenure in his Army leadership positions. During that moment he revealed that he developed the skills of mindfulness towards the conclusion of his US Military leadership role. He said, in retrospect he felt that if he had mastered this early on, he would potentially have felt less stress during the many challenges he faced.

Previously, Deanna Chaukos (Harvard) discussed in their paper, Risk and resilience factors associated with resident burnout, that 33% of first year residents experience burnout and of that group, they exhibited lower levels of mindfulness and coping skills and higher levels of depression symptoms, fatigue, worry, and stress.***

Fortney noted that in primary care physicians even brief mindfulness training was associated with prolonged improvements in burnout, depression, anxiety, and stress in physicians.****

During the 2020 ACS Clinical congress, Dr. Carter C Lebares, MD ***** (Director Center for Aging, Metabolism and Emotion Research, Dept Surgery University of California, San Francisco, CA.) participated on a panel discussion on Surgeon Well-being. Her topic, “Mindfulness for Surgeons: promoting evidence d-based practices through culture change”, was an eye-opener for me!

Dr. LeBares previously forwarded me a paper her team wrote in 2018 (Journal American College of Surgeont). In their paper, Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience, their group assessed burnout and several psychological characteristics that can contribute to burnout vulnerability or resilience in surgical residents. They concluded that dispositional mindfulness was associated with lower risk of burnout, stress, anxiety, suicidal ideation, and depression. We both meant to get together for us to discuss her mindfulness research but unfortunately we forgot.

Since then Dr. Lebares recently shared with me several concepts her group has been working on. One interesting area is the use of Enhanced Stress-Resilience Training to reduce generalized anxiety among surgery trainees to reduce burnout, depression and potential for suicide.

Enhanced Stress-Resilience Training (ESRT), teaches surgeons mindfulness and affective regulation skills.

In another recent paper “The efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized trial (Labares C et al, JAMAOPEN access 2019:2(5):e194108) Dr. Labares described resilience as “a means of adaptive coping that changes perceived stress through the development of cognitive habits. Mindfulness based interventions have been shown to enhance resilience and approve affect, executive function and performance in the military, police, and athletes. Mindfulness meditation training involves the cultivation of key cognitive skills, including the moment to moment awareness of thoughts, emotions and sensations, and the conscious awareness of cognitive processes.” In this study her group has been utilizing a modified mindfulness-based stress reduction program (including classes and home practice). Their team examined the effects of mindfulness training on subject MRI’s when the subjects viewed negative images. Subjects who participated in MMBSR had a higher activation in the medial frontal gyrus, superior frontal gyrus and precuneus/posterior cingulate cortex signifying the act of emotional regulation.

WHILE LISTENING TO HER RECENT PRESENTATIONS DURING THE AMERICAN COLLEGE OF SURGEONS VIRTUAL CLINICAL CONGRESS (Oct 2020), SEVERAL QUESTIONS CAME TO MIND THAT I ASKED TO DISCUSS WITH HER ON NOVEMBER 2nd 2020:

WHAT IS MINDFULNESS?

Dr. LeBares:

Mindfulness is a set of cognitive skills that one has inherently or trained in to allow one to experience stressful events in a less reactive way.

Three skills come to play during mindfulness:

1.      Awareness training- this is the moment to moment clear perception of one’s thoughts and emotions.

2.      Emotional regulation- aka affective regulation- not getting psyched out- when we are upset/scared but have the ability to not immediately react.

3.      Metacognition-aka perspective taking- the consciousness of recognizing how you feel and how to not react to those emotions. Surgeons have all experienced stress events/crises- we have an inherent manner to remain calm and take control.

 

 

HOW DOES YOUR PROGRAM DIFFER FROM OTHER MINDFULNESS PROGRAMS? WHAT IS THE BEST WAY TO INTEGRATE A MINDFULNESS PROGRAM INTO A SURGERY PROGRAM? IE SURGEONS TEND TO REFRAIN FROM ACKNOWLEDGING THEIR STRESS LEVELS UNTIL AN INCIDENT OCCURS. HOW DOES ONE SYSTEMATICALLY INTEGRATE THIS INTO A PROGRAM THAT HAS NO CURRENT FOUNDATION? HOW DO YOU TEACH AND OLD DOG NEW TRICKS?

Dr. LeBares:

ENHANCED STRESS RESILIENCE TRAINING (ESRT) is a formal mindfulness-based stress resilience training. The theory is that this can modify the hypothalamic pituitary adrenal axis.

1.      SURGERY ORIENTED: The whole purpose of ESRT is to capitalize on excellent research on mindfulness used by high stress high performance individuals (ie Army and Marines- comprehensive soldier fitness- resilient warrior training). However, the problem with surgery residency is the minimal time to add in this training. We had to figure out how to integrate this proven training into our limited hours. We trimmed the training down to a more reasonable process that can be effective in the limited time.  Everything is geared to surgery. We use relative scenarios such as ‘Where I used this in my OR, or my personal life”. We focus on real examples and reinforcement. We really try to take advantage of mindful walking- Learning to take those minutes to take advantage of clearing your mind before you go to work. Learning how one can manage the interruptions in life more effectively and break up the stress that we face.

2.      MODULAR TRAINING: must be taught with fidelity.  We use the anatomical context ie starting with the skeleton, then muscles and then skin. You can suit this to different situations. This process allows for modification. The skin is the video, and audio references.

Each training site takes this format and then personalizes it to their institutions.

One Instructor has taught police force and military specialists.

For this to work, you need matching personalities.

 


WHAT IS THE PROCESS TO INTEGRATE ESRT INTO ANOTHER INSTITUTION?

Dr. LeBares:

Most of the course will be available remotely starting in April. We have trained Surgeons and ED MDs in military and academic institutions.

Institutions can use their instructors and teach their people. Its best to do this in small groups. Then we then identify someone locally as local instructor who is then observed.

We are currently working with Lorrie Langdale at the University of Washington and Pierre F. Saldinger, MD New York-Presbyterian Hospital


HOW LONG DOES IT TAKE TO PERFECT THESE TRAITS AND PASS ONTO OTHERS?

Dr. LeBares:

Best way would be to take the course. It takes time! And you must continue to practice and learn.

DOES ONE NEED TO CONSCIOUSLY EXERT AN EFFORT TO UTILIZE MINDFULNESS TO MINIMIZE THE NEGATIVE CONSEQUENCES OF A NEGATIVE EVENT OR ARE THESE INGRAINED AND NATURAL AND SUBCONSCIOUS?

Dr. LeBares:

At first it is very effortful, but after 6 months it is commented that they are surprised about their subconscious use of these skills. The more you practice the more it is first nature.


CAN YOU EXPLAIN THE MRI STUDY TO ME PLEASE? WHAT DOES THIS MEAN? “HIGHER ACTIVATION IN THE MEDIAL FRONTAL GYRUS, SUPERIOR FRONTAL GYRUS AND PRECUNEUS/POSTERIOR CINGULATE CORTEX SIGNIFYING THE ACT OF EMOTIONAL REGULATION.”

Dr. LeBares:

·         Activation of ventrolateral prefrontal cortex (which includes the inferior frontal gyrus) is associated with reinterpretation of the affective stimuli to alter emotional impact. Our study proves that these images are provocative regardless who the person is. Provocation was seen in both intervention and control.

·         Activation of the Dorsolateral prefrontal cortex (which includes the middle and superior frontal gurus) is associated with the functioning of the executive control hub of higher order cognition. This is the area of filtering and responding to stimuli.

·         The precuneus (which is within the posterior Cingular’s cortex) is associated with mental imagery/ Interoception, Visio spatial motor skills/ bimanual skills and self-awareness/self-reference. It is the seat in the brain for our inner awareness. It allows you to comprehend “how might I solve this problem”.

Both areas are activated during mindfulness stress reduction. 

When ESRT trained residents are shown these images, they are able to recruit these areas of the brain to engage into problem solving.


Pernkopf Anatomy: Atlas of Topographic and Applied Human Anatomy : Head and Neck (Pernkopf Anatomy, Vol 1) (English and German Edition) (German) Subsequent Edition by Werner Platzer (Editor), Harry Monsen (Translator); Urban & Schwarzenberg; Subsequent edition (August 1, 1989)


HOW DOES MINDFULNESS TRAINING RELATE TO STATE VS TRAIT ANXIETY?

Dr. LeBares:

Only looking at State Anxiety as trait anxiety would require subgroups which would take a very long period to accrue. It is likely most effective in state anxiety (as opposed to those who are under constant stress/anxiety).

In the UK, mindfulness training is the gold standard for mental illness (they call it MBCT training).


KNOWING THAT STRESS INCREASES THE RISK FOR CHRONIC DISEASES AND BURNOUT WITH POTENTIAL SUICIDAL IDEATIONS OR ALCOHOLISM, ARE YOU SEEING A REDUCTION IN THESE CONDITIONS IN TEST SUBJECTS?

Dr. LeBares:

We have shown in the recent Annals Surgery article there is a diminished depersonalization by stress. In a single cohort study (no control) there was a reduction in alcohol intake, depression, and burnout in their first year. The stress of resident training is worse in the first 8 months. In their cohort, those with the training did better but without continued training the effects were not sustained. We learned that you need to practice continued mindfulness.

The question is how? Do you have to practice daily?

Is this feasible in isolation, or is it better with a group or with a guide or moment to moment during the day? Our advice is that participants practice daily up to 15 minutes.

Informal mediation seems to be the best connective pathway.


WHAT IS THE IMPORTANCE OF
ESRT EFFECT ON GENE REGULATION (TRANSCRIPTION FACTOR ACTIVITY) > 50% REDUCTION IN THIS RESPONSE”. CAN YOU EXPLAIN THE SIGNIFICANCE OF A REDUCED PRO-INFLAMMATORY RNA EXPRESSION IN YOUR ESRT SUBJECTS COMPARED TO CONTROLS? ANY CHANCE THIS COULD RELATE TO A REDUCTION IN ARTHRITIS, LOW BACK OR CERVICAL SPINE PAIN, MIGRAINES ETC

Dr. LeBares:

Steve Kohl, a molecular geneticist, assessed a collection of genetic measures for transcription levels of inflammatory proteins. He assessed the magnitude which these effector proteins are affected. Epigenetics is a real time activity. Regardless of origin of stress, all of these stressors activate the same pattern of gene transcriptions for fight or flight syndrome, inflammatory pathway and antiviral pathways. This is part of the hypothesis as to why people who are chronically stressed are sicker, that is they have worse medical comorbidities. This molecular genetic profile fits the effects of these disease states.

This team looked at these parameters in the control group who had gene pattern dysregulation alongside of decreases in antiviral activity. This magnitude of protein increase can be found in other types of stress groups.

We found that ESRT decreased that level by 50%. Your gene expression is not subjective- it is entirely objective.


Kenneth A. Lipshy
Www.crisismanagementleadership.com

www.crisislead.blogspot.com

 


* Dr. Sharmila Dissanaike is the Professor and the Peter C. Canizaro Chair of Surgery at TTUHSC. She is the former Medical Director of the John A. Griswold Level 1 Trauma Center and the Assistant Director of the Timothy J. Harnar Burn Center at UMC. She is active in clinical surgery, with a focus on critical care, trauma and burns.
**LTG (Ret) Eric B. Schoomaker Surgeon General of The United States Army 2007 to 2011 (prior to that he was the Commander of the N. Atlantic Regional Medical Command and Walter Reed Army MC). https://crisislead.blogspot.com/2016/06/lessons-on-resiliency-in-leadership-by_7.html
***Chaukos D, Chad-Friedman E, Mehta DH, et al. Risk and resilience factors associated with resident burnout. Acad Psy- chiatry 2017;41:189-194.
Deanna Chaukos dchaukos@partners.org
****Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013;11:412–420.
*****Carter Lebares- Assistant Professor of Surgery Division of General Surgery Director, UCSF Center for Mindfulness in Surgery
Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW,  Epel ES. Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience. J Am Coll Surg 2018;226:80-90.
The effect of mindfulness-based cognitive skills training on anxiety among general surgery residents during covid-19 Caitlin R Collins MD, MPH, Micaela L Rosser MD, Anya L Greenberg MBA, Carter C Lebares MD, University of California, San Francisco
A Feasibility trial of formal mindfulness based stress resilience training among surgery interns JAMA 2018/sur/08292018
Key factors for implementing mindfulness based burnout interventions in surgery Am J Surg 2019 in Press
Enhanced stress resilience training in surgeons: iterative adaptation and biopsychosocial effects in 2 small randomized trials. Annals Surgery In press 2020
Efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized clinical trial. JAMA 2019/05 24 2019.
Publications 
Enhanced Stress Resilience Training in Surgeons: Iterative Adaptation and Biopsychosocial Effects in 2 Small Randomized Trials.
Annals of surgery
Lebares CC, Coaston TN, Delucchi KL, Guvva EV, Shen WT, Staffaroni AM, Kramer JH, Epel ES, Hecht FM, Ascher NL, Harris HW, Cole SW
Key factors for implementing mindfulness-based burnout interventions in surgery.
American journal of surgery
Lebares CC, Guvva EV, Desai A, Herschberger A, Ascher NL, Harris HW, O'Sullivan P
Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial.
JAMA network open
Lebares CC, Guvva EV, Olaru M, Sugrue LP, Staffaroni AM, Delucchi KL, Kramer JH, Ascher NL, Harris HW
Feasibility of Formal Mindfulness-Based Stress-Resilience Training Among Surgery Interns: A Randomized Clinical Trial.
JAMA surgery
Lebares CC, Hershberger AO, Guvva EV, Desai A, Mitchell J, Shen W, Reilly LM, Delucchi KL, O'Sullivan PS, Ascher NL, Harris HW
Mindful Surgeon: A Pilot Feasibility and Efficacy Trial of Mindfulness-Based Stress Resilience Training in Surgery.
Burnout and gender in surgical training: A call to re-evaluate coping and dysfunction.
American journal of surgery
Lebares CC, Braun HJ, Guvva EV, Epel ES, Hecht FM
Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience.
Journal of the American College of Surgeons
Lebares CC, Guvva EV, Ascher NL, O'Sullivan PS, Harris HW, Epel ES
Burnout in US Surgery Residents: Do Year of Training and Mindfulness Matter?.

 

Friday, September 11, 2020

FAILING FORWARD- ALLOWING MENTORSHIP TO HELP YOU GROW

I recently listened to a talk by Dana A. Telem, MD, MPH* titled FAILING FORWARD.
In her talk, Dr. Telem discussed several aspects of failure during her career that resonated with me including:
·         Over confidence compounded by internal focus (a “I can do everything” without help), and a fixed mindset.
 
She moved on to state that she learned some valuable lessons thru her failures including:
·         Failures will happen to everyone and these failures make you better.
·         Leave your insecurities at the door and have trust in a mentorship and be a mentor. Her mentorship with Justin Dimick (see prior interview below), was invaluable, as he  fostered her harvesting her potential, created a culture of radical candor and always “had her back”.
 
Her fondness for her mentor raised some questions from me. It is known that “effective mentoring is critical to the success of early-stage investigators at academic health centers (AHCs). Strong mentorship has been linked to enhanced mentee productivity, self-efficacy, and career satisfaction.” I was curious how she has grown thru a successful mentorship relationship.
 
Dr. Telem:
1.      You indicated that your strong personality tended to hamper your development along the way. Most of us never understand that a strong independent personality can be counterproductive, until late in life. This is a valuable lesson. When did you first realize this about yourself? How did you gain the emotional intelligence to realize that? How do you teach that to junior faculty or trainees?
I am solution oriented and felt I did not need to bother others. That may help in a crisis but it did not work when trying to work with others. Asking for help does not make you weak- it is good to acknowledge you need help. It is hard for surgeons. It may be a fear that we will look weak if we are vulnerable, its uncomfortable. You feel you need to prove yourself before you can be vulnerable.”
 
2.      Technical skills tend to be the main focus of young trainees and attendings. I have discussed the importance of non-technical skills several times in the past with Steve Yule and Rhona Flin. Given the clinical work (and research work) they are responsible for,  it seems like a considerable challenge to engage trainees and junior faculty who feel that their focus should be on clinical medicine. How do you engage residents / trainees / young faculty on non-technical skills?
Our newer trainees feel charged to seek help, call out, unlike those that came before. Millennials are good at this.
It’s the culture that sets up this path. A culture of psychological safety builds this ability to learn Non-technical skills and to change. It has to start at the top leadership. I took over as the General Surgery Chief, but I have a Department chair that supports people no matter what the need. That tone and culture fosters this. Then it is not difficult to solicit that skillset. It is supportive and not punitive.
Trust is the key to this foundation. If you have trust it is not difficult.”

3.      Those of us who have a “I can do it on my own” mentality do not take to mentorship too easily.  how did that relationship develop? Was this arranged or fortuitous?  How did you ease into that relationship?
in residency I felt I had to do everything on my own. As a junior faculty, for clinical help it was a standard practice. But for administrative needs I just did not know what I needed and sought further training instead of a mentor. I earned multiple degrees trying to better myself. Coming to U. Michigan revealed the obvious- that you DO need help. Research was very intimidating for me when I came to U. Michigan. I was so worried about my interpretation of my research but Justin allowed me to realize that a mistake is fine and not a big thing. His blunt critique to make you better instills trust. This was the first time I really got that.”
 
4.      I recently picked up on this article in non-medical literature: “A mentor isn't always someone who has been there, done that before, who draws on his or her own experience to guide the younger less experienced person, but in some cases, a professional trained in coaching, who is guiding and advising people who are pursuing a wide range of goals and careers. In recent years, especially in the management and human resources literature, there are consultants whose job is to advise members of the business community on the mysteries of mentoring.” **
a.       What is your focus when it comes to trainees or junior faculty regarding mentorship? Is waiting for the trainee to request a mentorship or is there a process to proactively establishing that relationship?
If this is a scheduled process how is that conducted?
“Michigan promise- promise that we will develop all new faculty. Each new faculty joins a LAUNCH TEAM. There is a team of mentors for all research. These include sounding boards. There are advisors to support those who feel they may be in a rut. They are now tracking people in their internship and identifying those with promise.
Forced mentorship does not work. This system allows for pairing until a successful relationship has started. This just started so data is coming in for analysis. This will help with the different types of residents but mostly those that are just not sure where they want to go or to be- help them identify where they want to be.”
 
b.      What is the secret of a successful mentorship?
“Mentorship and sponsorship are different things. Mentorship can be impactful and change the course of your career and others who mentor from afar. Success comes when the mentor allows you to build yourself but not recreate them. Trust is key. Success comes from who are there whether you are successful or not. The mentor should let you be who you were meant to be.”
Listen to Julie Ann Sosa, M.D., M.A., FACS  UCSF Department of Surgery- transformational growth.
 
c.       Have you equated successful mentorship with increased productivity? Reduced burnout/ less stress? Do the residents who have successful mentorships have a more successful process in finding an ideal job or fellowship?
“Yes and yes! I had a lack of focus on priorities. If you don’t have focus, you don’t know what you want. Hard to be intentional. Hard for you to know what to look for. I decided I needed more training, more fellowships. I wrote a lot of papers and felt satisfied. But in retrospect I was not satisfied that these had any impact. It was not until I had a mentor that I trusted that if felt I could write and make an impact. I learned that the best writers were mentored by the best writers!”.
 
d.      Can you teach this old dog new tricks? Is it too late (at 58 years old) for me to find a mentor?
“Its never too late! learn from your peers!! Peer mentors are the best! The young trainees are so smart and can teach. .
 
**Mentoring: What Is It? How Do We Do It and How Do We Get More Of It? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875765/[8/3/2020 9:14:53 AM]
 
Kenneth A. Lipshy
Www.crisismanagementleadership.com
www.crisislead.blogspot.com
 
Dana A Telem MD, MPH, Department of Surgery University of Michigan, Vice Chair Quality and patient safety, division chief minimally invasive surgery.
 
INTERVIEW: INNOVATIVE STRATEGIES FOR IMPROVING SURGICAL PERFORMANCE Justin Dimick, MD, FACS; Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan.  https://crisislead.blogspot.com/search?q=dimick
 
Winston Churchill: “Definition of Success is the ability to move from failure to failure without losing enthusiasm”
“Relationships are as important as the task.” ANON
“in Failure cones strength and a new direction” ANON
“there’s almost nothing to learn from success. Failure’s the best teacher you will ever have” Blue Bloods.
“when something blows up in your face try again, try again, try again and eventually you will be on top” Wernher von Braun. V2 Rocket creator. NASA rocket engineer.
And the contradiction in philosophy, “The human condition actually prevents us from adopting lessons learned” Dr. Emily Mayhew, PhD, London. WWI 100th anniversary recognition Excelsior lecture 2018.