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, 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?
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?
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?
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?
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?
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.”
· 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.
HOW DOES MINDFULNESS TRAINING RELATE TO STATE VS TRAIT ANXIETY?
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?
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
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.
* 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.
****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.
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.
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?.