June Shannon reports on a stress management approach that has been specifically adapted for Irish GPs and is set to make its debut in this country next month
International studies have shown that compared to the general population, doctors have higher levels of stress and anxiety, making it important for members of the medical profession to look after their mental health.
This month, the ICGP is running the country's first course in mindfulnessbased stress reduction (MBSR) aimed specifically at GPs. Bray GP Dr Rita Doyle and psychotherapist Debbie Correll will facilitate the eight-week course, which has been approved by the College's Health in Practice Committee.
Mindfulness can be described as developing moment-to-moment non-judgemental awareness. It is a mode of concentration or the practice of focusing on the here and now, including what is happening within the body.
With its roots in Buddhist meditation practice, MBSR was developed by Jon Kabat-Zinn, PhD, Professor Emeritus of Medicine at the University of Massachusetts Medical School in the late '70s and since then it has been applied to a wide range of medical and therapeutic areas.
In the book, The Mindful Way Through Depression - Freeing Yourself from Chronic Unhappiness by Mark Williams, John Teasdale, Zindel Segal and Jon Kabat-Zinn, mindfulness-based cognitive therapy (MBCT) is described as a practice that "brings together the latest in understandings of modern science and forms of meditation that have been shown to be clinically effective within mainstream medicine and psychology".
"The novel yet potent synthesis of these different ways of knowing the mind and body can help you make a radical shift in your relationship to negative thoughts and feelings. Through this shift you can find a way to break out of the downward spiral of mood so that it does not become depression."
The programme can cut the risk of relapse by half in those that have had three or more episodes of depression, the book states.
According to a 2005 paper in the International Journal of Stress Management on Mindfulness-Based Stress Reduction for Health Care Professionals: Results from a Randomized Trial, "the MBSR intervention is designed to teach participants to become more aware of, and relate differently to, thoughts, feelings and body sensations. MBSR helps participants cultivate a non-judging (sic) yet discerning observation of all the stimuli that enter their field of awareness moment by moment".
"Mindfulness practice allows for greater awareness of the ‘here and now', as the practitioner learns to let go of ruminations about the past and fears regarding the future. In this way, practitioners learn to see their habitual reactions to stress and to cultivate healthier, more adaptive ways of responding. The essence of mindfulness involves awareness and acceptance of whatever is occurring in the present moment."
It also stated that in light of the significant stress reported by healthcare professionals and the deleterious consequences of this stress on their lives, it seems important to begin to seriously explore more effective means of supporting them.
"Further, given that job burnout and distress have been significantly associated with decreased patient satisfaction (Garman, Corrigan, & Morris, 2002) and suboptimal self-reported patient care (Shanafelt et al. 2002), incorporating MBSR interventions for healthcare professionals also has the potential to enhance patient care."
The paper concluded that MBSR offered "a well-established model for providing a brief, cost-effective program that can be implemented easily in hospitals and healthcare clinics".
Dr Doyle is a trainer and former CME tutor with the ICGP with a specific interest in psychological issues. She has also completed a two-year programme in CBT and has a keen interest in self-care and its development within the profession. Coupled with practising mindfulness herself, Dr Doyle also recommends it to some of her patients to help with a range of conditions such as depression and has seen some very positive results.
According to Dr Doyle, mindfulness has been scientifically proven to be useful in the management of chronic pain, stress and anxiety and skin conditions such as psoriasis.
"There is a huge amount of hard evidence out there to show that mindfulness is very effective in lots of clinical situations," she said.
MBSR and MBCT are also widely used in the area of cancer support to help patients overcome difficulties associated with treatment and the many other worrying aspects of a cancer diagnosis. It is also being used in cardiac rehabilitation.
According to Dr Doyle, mindfulness can be used as a tool to both prevent and treat stress. Interestingly for the medical profession, it has also been shown to have a number of additional benefits such as improving consultation and listening skills and reducing compassion burnout and fatigue.
The well-known Irish palliative care specialist Prof Michael Kearney, now working as the Medical Director of the Palliative Care Service at Santa Barbara Cottage Hospital, Santa Barbara in the US, was one of the authors of a study published in the Journal of the American Medical Association (JAMA) last year, which recommended the use of mindfulness meditation as a way of helping with burnout among palliative care physicians.
According to the paper, entitled ‘Self-care of Physicians Caring for Patients at the End of Life', burnout results from stresses that arise from the clinician's interaction with the work environment, while compassion fatigue evolves specifically from the relationship between the clinician and the patient. Clinicians who care for dying patients are at risk of both.
According to Prof Kearney's paper, "mindfulness meditation is now widely used by both clinicians and patients for its psychological benefits in a variety of healthcare settings. The psychological benefits include reducing anxiety; enhancing a sense of wellbeing; alleviating pain; increasing empathy; tapping repressed material in the unconscious; and gaining a greater sense of self-actualisation, self-responsibility, and self-directedness."
Furthermore, a paper published in JAMA in September last year looked at the association between training in mindful communication and burnout, empathy and attitudes among primary care doctors in New York. According to the paper, "primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care."
The research involved a before-and-after study of 70 primary care doctors who took part in a mindfulness course between 2007 and 2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material and discussion.
The eight-week intensive phase was followed by a 10-month maintenance phase.
Over the course of the programme and follow-up period, participants demonstrated improvements in mindfulness, burnout, depersonalisation and personal accomplishment. Improvements were also seen in the physician belief scale total mood disturbance and personality and emotional stability. Improvements in mindfulness were correlated with improvements in total mood disturbance, perspective taking subscale of physician empathy, burnout and personality factors.
The authors concluded that participation in a mindfulness communication programme "was associated with short-term and sustained improvements in well-being and attitudes associated with patientcentred care".
The ICGP eight-week training programme is based on the seminal work of Dr Kabat Zinn and Dr Michael Krasner, Associate Professor of Clinical Medicine at the University of Rochester School of Medicine and Dentistry in New York, with specific adaptations for doctors in general practice here in Ireland.
There are two key projected outcomes for doctors who participate in the full programme:
- Enhanced occupational health: This prophylactic programme is designed to mitigate the development of GP occupational hazards such as burnout.
- Enhanced patient care: Participation in a mindfulness-based programme is associated with increased attentional expertise with sustained improvements in patient care. Reduction in burnout has a direct correlation on the improved quality of the doctor/patient relationship.
This first course will be run as a pilot project but the College has said it may decide to run further courses in this area of stress reduction for GPs, should there be a demand for such courses in the future.
To those GPs with an interest in the concept of mindfulness, Dr Doyle's advice is simply to "dip your toe in the water and see what you think".
Be Mindful Campaign
- The British Mental Health Foundation recently launched www.bemindful.co.uk
- In January, the UK mental health charity released a report calling for people who suffer repeated episodes of depression to be offered MBCT, a clinically-approved treatment based on meditation techniques.
- The NICE guidance for the NHS has recommended MBCT for recurrent depression since 2004. However, the Be Mindful report revealed that five years on, just one in five GPs in England say they can access the treatment for their patients and only one in 20 prescribe MBCT regularly.
- The Mental Health Foundation is calling for the NICE clinical guidelines for depression to be fully implemented and for all patients with recurrent depression to be offered MBCT. The treatment consists of an eight-week course in mindfulness meditation, alongside elements of cognitive behavioural therapy and yoga.
- The number of prescriptions made each year for antidepressants in England has doubled in the last decade, reaching 36 million in 2008. The Be Mindful report found that three-quarters (75 per cent) of GPs have prescribed medication to people with long-term depression, although they believed another treatment would have been more appropriate.
- The charity argues that MBCT would be a valuable alternative to antidepressants for GPs and patients. A large majority (72 per cent) of GPs believe mindfulness meditation would help their patients who have mental health problems while nearly all (93 per cent) think there should be greater availability of other effective treatments for recurrent depression, in addition to medication.