How to Heal the Healer: Combating Burnout Using Compassion and Mindfulness-Based Interventions
1. Department of Psychiatry, SUNY Upstate Medical University, Syracuse, NY, USA
2. Psychiatry and Behavioral Sciences, SUNY Upstate Medical University, Syracuse, NY, USA
Academic Editor: Steven K. H. Aung
Special Issue: How Compassion Benefits the Healing Process
Received: June 13, 2019 | Accepted: July 15, 2019 | Published: July 24, 2019
OBM Integrative and Complementary Medicine 2019, Volume 4, Issue 3, doi:10.21926/obm.icm.1903047
Recommended citation: Dick MH, Khoury NM. How to Heal the Healer: Combating Burnout Using Compassion and Mindfulness-Based Interventions. OBM Integrative and Complementary Medicine 2019; 4(3): 047; doi:10.21926/obm.icm.1903047.
© 2019 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
With each passing year, depression, suicide, and burnout have become more and more prominent issues in medical practice and training, gaining significant public exposure recently. It is now well documented that rates of suicidal ideation and depression are higher among physicians than the general population and the phenomena of burnout in medicine warrants public health attention for patients and caregivers alike [3,4] . Burnout can be defined as a response to the chronic interpersonal stressors of one’s job, involving overwhelming physical and/or emotional exhaustion, feelings of cynicism and detachment from one’s work, and a sense of ineffectiveness or lack of accomplishment .
While there may be new stressors contributing to what is now known as burnout among medical caregivers, feelings of inadequacy, fear of failure, and the brutality of illness and suffering are not unique to the healers of this century. John Berger and Jean Mohr’s book, “A Fortunate Man”, documents in both prose and imagery, the life of a country General Practitioner in Great Britain, John Sassal . While they capture the suffering of Sassal’s patients, they also allow the reader to bear witness to Sassal’s pain in the form of those above-mentioned symptoms of exhaustion, detachment, and feeling a lack of accomplishment. The reader witnesses Sassal’s own descent into what we now know as burnout, as he acts as surgeon, physician, and even psychotherapist to his small, underserved community.
The primitive medicine man, who was often also priest, sorcerer and judge, was the first specialist to be released from the obligation of procuring food for the tribe…An awareness of illness is part of the price that man first paid and still pays for his self-consciousness. This awareness increases the pain or disability .
Sassal eventually died by suicide, an event that was not documented in the book. Is burnout then, and the fear and suffering inherent in it, the “price we pay” for our medical expertise? Does the increased “pain or disability” fall ultimately on the healer as well as the patient?
Unfortunately, the price paid for this calling appears to begin as early as medical school. In a study of medical students at seven U.S. Medical Schools, the one-year prevalence of suicidal ideation was 11.2%, significantly higher than the 6.9% among the general population of 25-34 year-olds . A meta-analysis of studies investigating the prevalence of depression and suicidal ideation among medical students demonstrated that 11.1% experienced suicidal ideation while in medical school and 27.2% screened positive for depression; even more concerning, the same meta-analysis found that only 15% of students who screened positive for depression sought treatment . The ambiguity of Berger’s words on said “awareness” may be quite telling in this regard. Is there something inherent in knowledge of and witnessing disease that places the burden on our shoulders as well? If so, then what is our responsibility to our students, to ourselves, and our patients to treat and alleviate the suffering we as providers also endure?
2. Changing the Culture of Medical Education
Recall an experience of medical school orientation: it may start by waxing poetically on the privileges of this “calling”, the relationships we build with those under our care, and the events that we witness, in addition to the grueling work and sacrifice. We heard talk of empathy and compassion, in the same lines as autonomy, justice, beneficence and nonmaleficence. Yet, not infrequently, we fail to extend some of these principles to ourselves, forgoing self-care necessities such as sleep, proper nutrition, time with one’s family/friends, or relaxation to care for our patients. We allow ourselves to be the exceptions to the very principles to which we hold our care for others. We do not treat ourselves nor our colleagues with the justice or equity with which we are taught to treat our patients. Moreover, the system of medical training often makes it difficult to maintain the values set forth.
Indeed, wellness in medical education often gets relegated to the responsibility of the individual. In residency training, self-care is often a task that individual trainees are expected to figure out on their own time. Of course, self-care may be highly personal. However, the drivers of burnout clearly go beyond the individual to encompass factors on work unit, organizational and national levels; within these levels are multiple known drivers such as workload and job demands, resources, culture and values, control and flexibility and work-life integration, to name a few . In a 2016 review of interventions targeting physician burn-out, West and colleagues identified 15 randomized control trials and 37 cohort studies and found that organizational interventions were more effective than individual-focused ones . These included shortened rotation and shift length, modifying clinical work processes, and also small group curricula, self-care, and communication skills training . While such practical interventions are critical, there is also value in fostering mindfulness and compassion in trainees and in creating a culture within medicine where these practices occur intentionally and in community.
3. Connections between Compassion and Mindfulness
Compassion has increasingly become a target in itself to reduce burnout and improve wellbeing among health care professionals. As physicians at SUNY Upstate, we are interested in interventions that seek to target the development of compassion and mindfulness in medical providers, starting from the beginnings of medical training. If empathy is the ability to see another’s perspective and feel their emotional reaction, compassion is a step beyond that, defined by a desire to help. Mindfulness and compassion are related concepts and practices. Compassion is an implicit part of all mindfulness practices, which emphasize attending to present experiences and accompanying sensations and thoughts in a nonjudgmental manner. Yet compassion-based interventions are relatively newer in the field of burnout prevention and wellness among healthcare providers.
4. Compassion and Mindfulness Interventions that Work
Indeed, mindfulness training in healthcare has been more widely applied and studied. As Gurland notes in a recent editorial on mindfulness practices in surgical residents, mindfulness, unlike other forms of self-care and relaxation, such as exercise, alcohol, watching television, is not an escape from uncomfortable experiences; it is a way to directly observe the workings of our own minds to become more disciplined, more accepting, and less reactive . The study in question, conducted by Lebares et al., found preliminary evidence that such interventions improved both resident wellbeing and performance . Other developed programs include a Mindful Practice program developed by Epstein and colleagues for healthcare professionals, proposing that mindfulness provides a means to become more effective clinicians by increasing engagement in the cognitive and technical aspects of medicine, while also creating more satisfying relationships between patient and provider . This program and others like it highlight that medicine and meditation (a practice of mindfulness) share etymological roots, with mederi, meaning "to heal” . Both compassion and mindfulness are critical to progression through medical training and good patient care. However, given the crisis of burnout in the medical profession, can applying these principles to ourselves be of benefit?
5. Interventions as Prevention
There exist a range of interventions/treatments that aim to develop compassion and mindfulness as a critical point in prevention, specifically in medical training. In one important recent study using a specific compassion-based intervention, Cognitively-based Compassion Training (CBCT), Mascaro et al. examined its use in second year medical students and showed that there was indeed positive differences in depression, loneliness, sleep, and increased compassion over the course of the intervention in comparison to a wait-list group . Additionally, those students who reported higher levels of depression pre-intervention were noted to receive more benefit in compassion scores than the other students . This shows the possibility that such interventions can assist the majority of students, and may also help in alleviating depressive symptoms and improving compassion in the most vulnerable students. This study highlights what many of us in the caring professions have suspected, that our mental and physical well-being are linked to our ability to be compassionate providers. It also raises the important questions of whether or not medical training itself leads to this decrease in compassion as it progresses, and if compassion can be a buffer against depression among medical providers.
6. Importance of Group Interventions and Fostering Community
Compassion seems to be linked to personal wellbeing, partly by increasing social relationships. So, does compassion-based training among medical providers improve loneliness (as reported in the Mascaro study) through improving relationships ? Looking at the skills of CBCT, this assumption would appear natural, as skill development starts at attention and stability of mind, leading to active compassion for others, with progressing steps of cultivating self-compassion, gratitude for others, and empathy . While these steps could be delivered individually, one power of group interventions involves realization of common humanity. This skill of developing gratitude for others in CBCT may emphasize the importance of offering these interventions as a group activity, rather than a personal practice, or responsibility.
Medical training limits the amount of time one has for others, in addition to self-care endeavors, such as exercise, healthful eating, and spiritual and/or religious practices. In summation, it affects one’s relationships with others and with one’s self. At times it feels impossible to balance academic success, family and other relationships. Providing medical trainees with the tools to success includes creating space, time and practice opportunities to work towards integrated wellness, or in the very least, help prevent depression. Encouraging such self-care and self-compassion in a group setting emphasizes the commonality in our own suffering, and highlights development of compassion for self into compassion for others.
At SUNY Upstate, we have begun to integrate these reflective practices into the psychiatry clerkship for all third-year medical students and are studying its effects on medical student burnout and wellness. There is often tension between mandated vs voluntary self-care practices; yet, a powerful message is sent when these practices are integrated into the routine of everyday learning. We are offering self-compassion practices, mindful movement, meditation, reflective writing and listening practices to engage our medical students. These tools can be useful in any field of medicine and in psychiatry they are particularly useful, given that our capacity to listen, be present and engage our patients in compassionate ways is our most valuable instrument.
As medical professionals and trainees, turning our compassion and desire to heal inwards allows for a truly just application of skill, providing benefit to ourselves and to our patients. It reaffirms the importance of adhering to the principles of beneficence and nonmaleficence for our own regard, without sacrificing that of our patients. Recall another introductory lesson during medical school orientation: the importance of self-care. We are frequently told that it is important to get sufficient sleep, regular exercise, and maintain contact with friends and family. However, as physicians, focusing on ourselves is often an impossible ideal and often feels selfish and wrong to caregivers who value altruism. For many years society has placed physicians on a pedestal as self-sacrificing martyrs who faithfully and diligently meet the needs of their patients, creating a character not unlike that of the general practitioner from Berger's book. But we know the ending of that story, and we owe it to future generations of physicians to change that narrative. After all, “…a man’s worth to himself is expressed by his treatment of himself” . Emphasizing self-care in the form of compassion and mindfulness training shows dedication to the principles of medicine from which we have traditionally excluded ourselves.
Dr. Dick is the primary author. Dr. Khoury contributed to discussion of interventions implemented at SUNY Upstate. Both Authors reviewed and edited the entire manuscript.
No funding was provided for this project.
The authors have declared that no competing interests exist.
- Mascaro JS, Kelley S, Darcher A, Negi LT, Worthman C, Miller A, et al. Meditation buffers medical student compassion from the deleterious effects of depression. J Posit Psychol. 2018; 13: 133-142. [CrossRef]
- Gurland B. Mindfulness-Based training improves technical skills and emotional regulation for surgical residents effects of mindfulness-based training for surgical residents invited commentary. JAMA Netw Open. 2019; 2: e194087. [CrossRef]
- Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and Suicidal Ideation among U.S. Medical Students. Ann Intern Med. 2008; 149: 334-341. [CrossRef]
- Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016; 316: 2214-2236. [CrossRef]
- Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016; 15: 103-111. [CrossRef]
- Berger J. A fortunate man: The story of a country doctor. New York: Vintage Books; 1997. p. 64, 166.
- Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017; 92: 129-146. [CrossRef]
- West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016; 388: 2272-2281. [CrossRef]
- Epstein RM. Mindful practice in action (I): Technical competence, evidence-based medicine, and relationship-centered care. Fam Syst Health. 2003; 21: 1-9. [CrossRef]
- Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008; 300: 1350-1352. [CrossRef]