Overview

The innovators implemented a CME course for primary care physicians to address burnout, incorporating mindfulness meditation, narrative medicine, and appreciative inquiry.

Organization Name

University of Rochester Medical Center

Organization Type

• Academic Medical Center

National/Policy Context

• A 2018 survey of University of Rochester Medical Center healthcare personnel found that the burnout rate among physicians was 41.6%, comparable to national physician burnout rates.
• In a 2008 survey of matched patient-physician pairs, physician burnout was associated with lower patient satisfaction and longer patient-reported recovery time (r = 0.23, p <0.05) and patient satisfaction (r = -0.16, p <0.05). There was also a significant correlation between patients’ perceptions of health care depersonalization and both recovery time (r = .32, p <0.01) and patient satisfaction (r = -0.58, p <0.01).

Leadership

Drs. Krasner and Epstein investigated, drafted, and edited a session-by-session curriculum guide.

Funding

The study was funded by the Physicians’ Foundation for Health Systems Excellence and sponsored by the New York Chapter of the American College of Physicians.

Research + Planning

• • All 871 primary care physicians in the Greater Rochester area were invited to join the program. Primary care physicians were recruited through the local medical society’s mail and electronic communications. The course was offered for free with CME credits for course participation and $250 for completion of five surveys in association with the pilot.
    • The surveys were administered at the following time points:
      • During registration (on average 37 days before the start of the program)
      • At the start of the first session (baseline survey)
      • At the end of the eighth weekly session (8-week survey)
      • At the conclusion of the last monthly session (12-month survey)
      • 3 months after the program ended (15-month survey)
    • The surveys included the following measures:
      • 2-Factor Mindfulness Scale: a scale in which mindfulness is captured as a multifaceted attribute related to one’s thoughts, perceptions, sensations and feelings. The two subscales used were:
        • Observe subscale: an 8-item instrument that measures “observing/noticing/attending to perceptions/thoughts/feelings”
        • Nonreact subscale: a 7-item instrument measuring the ability to “step back,” “pause,” and “recover” and “let go” when facing “distressing thoughts or images”
      • Maslach Burnout Inventory: a 22-item instrument with three subscales: emotional exhaustion, depersonalization, personal accomplishment
      • Jefferson Scale of Physician Empathy: a 20-item instrument that measures empathy via 3 dimensions: perspective-taking, compassionate care, and standing in the patient’s shoes
      • Physician Belief Scale: a 32-item validated measure of physicians’ beliefs about psychosocial aspects of patient care
      • Big Five Factor Structure personality scale mini markers: a validated set of 40 adjective markers of the 5 major personality dimensions:
        • Extraversion: energy, activity, sociability, and positive mood
        • Agreeableness: trust, warmth, caring, and cooperation
        • Conscientiousness: diligence, reliability, and organization
        • Emotional stability: reflecting emotional equanimity
        • Openness: interest in aesthetic and novel experiences
      • Profile of Mood States: a 65-item instrument to assess 6 mood-states: tension-anxiety, anger-hostility, confusion-bewilderment, depression-dejection, fatigue-inertia, vigor-activity
    • Ultimately 70 physicians agreed to participate in the program. 60 physicians completed the surveys mentioned above.

Tools or Products Developed

Development of surveys that participating physicians filled out to evaluate impact of the pilot (see ‘Other Steps to Implementation’)

Team Members Involved

• Physicians

Workflow Steps

• The program was broken up into an intensive phase and a maintenance phase
  • Intensive phase (2 months): consisted of eight weekly 2.5-hour sessions with a 7-hour session between the sixth and eighth session.
  • Maintenance phase (10 months): consisted of ten monthly 2.5-hour sessions
• 2.5-hour sessions generally consisted of four aspects:
  • 15-minute didactics about the week’s theme, such as:
    • awareness of thoughts and feelings
    • perceptual biases and filters
    • dealing with pleasant and unpleasant events
    • conflict management
    • burnout prevention
    • meaningful experiences in practice
    • setting boundaries
    • attraction to patients
    • self-care
    • being with suffering
    • end-of-life care
  • Formal mindfulness meditation, in which participants engaged in yoga-type exercises and other guided mediation techniques
  • Using narrative medicine techniques to write about personal experiences and share stories in pairs and small groups, as well as using appreciative inquiry to talk about successful methods to handle difficult clinical situations
  • Large group discussion of the effects of mindfulness, narrative writing, and appreciative inquiry, especially in the context of medicine and other aspects of participants’ lives
• During the 7-hour session, physicians participated in guided silent mindfulness practices.

Where We Are

• This course was initially held in 2007-2008 in Rochester.
• Since then, the innovators have offered similar “Mindful Practice” courses nationally and internationally.
• Now, the format for the sessions varies from 4-day residential workshops to 2-day workshops with subsequent webinars to half day workshops. The Mindful Practice programs also include facilitator training workshops. The innovators have also created versions of the curriculum specific to medical students and residents.

Outcomes

• Level of mindfulness: Improved mindfulness based on the 2-Factor mindfulness scale (raw score, 45.2 to 54.1; raw score change [Δ], 8.9; 95% confidence interval [CI], 7.0 to 10.8)
  • • Improvements in mindfulness were correlated with improvements in total mood disturbance (r = −0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = −0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001).
  • Severity of burnout symptoms: Decreased burnout symptoms based on the Maslach Burnout Scale (emotional exhaustion, 26.8 to 20.0; Δ = −6.8; 95% CI, −4.8 to −8.8; depersonalization, 8.4 to 5.9; Δ = −2.5; 95% CI, −1.4 to −3.6; and personal accomplishment, 40.2 to 42.6; Δ = 2.4; 95% CI, 1.2 to 3.6)
  • Level of empathy: Improved empathy based on the Jefferson Scale of Physician Empathy (116.6 to 121.2; Δ = 4.6; 95% CI, 2.2 to 7.0)
  • Physicians’ outlook on patients’ psychosocial issues: Improvements in the Physician Belief Scale (76.7 to 72.6; Δ = −4.1; 95% CI, −1.8 to −6.4)
  • Physician mood/personality:
    • Fewer mood disturbances based on the Profile of Mood States (total mood disturbance score of 33.2 to 16.1; Δ = −17.1; 95% CI, −11 to −23.2)
    • Improved personality subscores (conscientiousness, 6.5 to 6.8; Δ = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Δ = 0.5; 95% CI, 0.3 to 0.7)

Benefits

• Physicians taking the course experienced improvements in mindfulness, empathy and mood, all of which can lead to better patient-oriented medical care.
• Physicians also experienced decreased burnout, which is associated with better personal well-being.
• CME credit for the course provides incentive for physicians to participate in the program.

Unique Challenges

• Generalizability: It is unclear if programs like this course would help physicians in other specialties or in other practice settings, as many of the participants in this course were family physicians and did not practice in rural areas.
• The innovators were not able to measure the direct effect of the course on clinical care.

Sources

Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009 Sep 23;302(12):1284-93.