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?
|
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. |
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.
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.
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
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?.
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