Calm In The Chaos: Mindfulness As The Prescription For Physicians

Burnout, stress, and disconnection — these are some of the consequences of working as a physician today. The increasing time constraints, mounting technology requirements, demanding patient schedules, changing economic landscape, and continuous attention to the suffering of others put physicians in a state of constant sympathetic-nervous-system overdrive.

We can’t always change these aspects of our profession, but we can change our brains. By practicing mindfulness skills, physicians can increase their capacity for a deeper sense of calm and compassion that can help them manage difficult moments with greater resilience and equanimity.

When it comes to healthcare and well-being, we like to know that what is being prescribed has been tested and that evidence suggests its effectiveness. Recently, we have seen a steep rise in the research pointing to mindfulness and compassion as reliable ways for physicians to improve their resilience, performance, relationships, and well-being. According to the American Mindfulness Research Association, the number of mindfulness studies published in journals increased from 10 in 2000 to nearly 700 in 2016. Although our understanding is expanding rapidly, the field is still emerging.

Practicing Mindfulness

Most people believe mindfulness is something to add to an already full schedule, a special skill that only a few people can learn, or something that works only for people who have a baseline personality of being calm.

Actually, practicing mindfulness is about learning, bit by bit, how to train your attention to stay in the present instead of ruminating over the past or worrying about the future. The more you practice, the more mindful you become, and the more vividly you see the world as you tune into the moment with all your senses. In time, you cultivate a different way of being that is more focused, aware, and compassionate.

Mindfulness is the awareness that arises when we deliberately direct our attention toward our inner experience, toward others, and toward the environment around us; however, it’s more than just focusing our mind, it’s about our mindset — the attitude or filter through which we view the world. Mindfulness reinforces a mindset of being open, receptive, accepting, and compassionate, and that starts with acknowledging our natural tendency to judge, assume we already know something, or resist what life brings or what is out of our control.

As we practice mindfulness, we begin to notice shifts: from being on autopilot, distracted, uneasy, worried about the past or the future, to being alert, open, and tuned into the present; from being reactive in difficult moments to being able to take a breath and respond with equanimity and grace; from being lost in thought and judging how things and people should be to seeing things as they are with a clear, open friendliness. We put down our ruler of comparison or expectation and learn acceptance and skillful action.

Meditation or Mindfulness?

Meditation is to mindfulness as physical exercise is to fitness. Meditation is a body of mental training exercises — and there are many — that are designed to develop skills, strengthen our mind, and produce immediate states and long-term traits. A meditation session unfolds over a set time to produce an enhanced mental state, and it begins with the intention of the meditator: I want to calm my mind and body. I want to open my heart toward this patient. I intend to empathize with my colleague and try and see his perspective.

Over time, states become traits as the effects of neuroplasticity take shape. We hardwire our brain for well-being. We also can integrate meditation in micro-doses throughout the day. By approaching our day more mindfully, we can create calm in the chaos. Seek out quiet. Seed in mini-breaks during the day to move attention from our over-active mind and drop into the senses. Close our eyes and take a deep breath; each exhale taps into the calming, parasympathetic nervous system.

The Science of Mindfulness

In the book Altered Traits, Daniel Goleman and Richard Davidson share scientific confirmation that sustained practice can bring about enduring changes in brain function as well as observable transformation in behavior that stretches former ideas on human possibility.(1)

We know that the brain is highly trainable. We can change our mental patterns through repeated practice of new mindsets and habits — a concept called neuroplasticity. Through the repetition of mental practices like mindful breathing meditation and compassion meditation, we can strengthen the areas of the brain associated with self-awareness, attentional control, emotional regulation, and compassion.

A physician who is used to working in high-pressure conditions reported that he immediately saw results. He started paying attention more, listening to his partner with more care, and playing catch with his son, watching the ball, and listening to every word.

The science is compelling. A study from the University of California, Santa Barbara, showed that a mere eight minutes of mindfulness practice improved concentration and reduced mind-wandering.(2) Researchers found that mindfulness has a substantial effect on working memory, which helps us store and use data to make sound decisions in a timely manner. Students who participated in a two-week mindfulness program increased their Graduate Record Examinations (GRE) by 30 percent.(3,4)

Other studies have found that meditators lose less gray matter over time compared with non-meditators, and that meditation may reduce the cognitive decline associated with aging.(5) Meditation has been shown to alter gene expression,(6) lower the body’s inflammatory response to disease and other stressors,(7) and lengthen telomeres, a marker for longevity of life.(8)

Brewer and his team at the Center for Mindfulness at the University of Massachusetts Medical School,(9) as well as research by Yu Tang,(10) suggest mindfulness can undercut addiction. Solid results are emerging in the study of compassion, an area especially significant for countering the effects of empathic fatigue, stress, and burnout that are rampant in healthcare.(1)

For all the research showing the benefits of mindfulness, researchers still don’t know exactly how it works. Brewer describes the frontier for his team as understanding the nuances of the underlying mechanism and developing targeted treatment, not unlike the evolution of cancer therapies.

One of the most powerful benefits emerging is that mindfulness practice helps us learn to be with unpleasant experiences and thoughts and explore them with interest, acceptance, and non-judgment. For physicians, the capacity to be open and accepting, even if the procedure, the patient, or the experience is difficult, seems to be a critical driver of the stress-reduction benefits we see with mindfulness interventions.

Compassion: Sensing What Will Best Serve

It might seem counterintuitive that compassion — an awareness of others, a mindset of wishing well for others, and the ability to sense what will best serve — has measurable benefits for physicians, not just for patients. Brain-imaging research by Singer at the Max Planck Institute suggests that compassion training increases our capacity to be attentive to the emotional and physical pain of others, allowing us to help without paying the cost ourselves.(11)

When we connect with another person who is suffering, which takes courage and even vulnerability, we connect with the place in ourselves that knows suffering. Our attention shifts away from ourselves (I’m so stressed) toward focusing on others (*What would best serve here?). *This is highly correlated with well-being.

Davidson found compassion training, such as loving-kindness meditation (steps outlined later), can produce effects in as little as eight days to two weeks of practice. Brain scans after two weeks of training showed increased activity in circuits for attention, perspective taking, and positive feelings. Similar findings at Stanford University’s Center for Compassion and Altruistic Research and the Max Planck Institute show that compassion training yields a focus on others, perceived similarity, prosocial behavior, feelings of connection, closeness to strangers, and an increase in positive emotions.(12)

Mindfulness is the first step in empathy and compassion, and it all starts with being present to what is happening with openness instead of judgment.

Ironically, it usually is not being compassionate that creates burnout and fatigue for physicians. It is what gets in the way of being present and compassionate that leads to reduced well-being, burnout, and inferior patient care.

Obstacles To Being Present With Compassion

Some researchers suggest that as early as medical school, a mindset becomes instilled that physicians need to keep an emotional distance from patients and create a protective barrier against getting too close, or they will experience emotional contagion, the experience of getting caught up in the emotions of another. There is an assumption that hardening their hearts and keeping suffering at arm’s length might provide a shield against the suffering of others, in turn reducing their own suffering.

As Singer has pointed out, the opposite is closer to the truth. When we are under pressure, we reduce our capacity to be skillful, wise, and caring. When we encounter difficult situations or people, our amygdala fires and we trigger the physical and emotional aspects of the stress response. Our system floods with cortisol and adrenaline. We contract our bodies. We withdraw from others, disconnect, and ruminate on our favorite subject: ourselves. We say things we regret, avoid decisions, seek approval, push too hard, or surrender our power. We are much less able to be present and compassionate.

Practices To Strengthen Mindfulness And Compassion

Here’s the bottom line and the opportunity: We can learn to radically shift how we relate to our daily experiences and to other people and to cultivate the capacity to be more mindful and compassionate. Like most things, it takes intention, commitment, and practice.(13)

Mindful Breathing

Mindful breathing improves the ability to focus attention, stabilize the mind, and calm the body.

1. Find a quiet place and a comfortable posture. Sit or stand in a way that is alert and relaxed, with your feet firmly on the floor and your hands resting easily. Gently close your eyes.

2. Use the breath as an anchor of attention. Take a few deep breaths to sense where you can feel the breath most easily: as air coming in at the nose or the rise and fall of the chest or abdomen. Wherever you can most easily discern the breath can be your anchor of attention.

3. Recognize and return. Feel your natural breath, paying attention to the inhale and exhale, relaxing into each breath. After a few breaths, when your mind wanders, as it will naturally do, simply notice it and gently return your attention to the breath. Before you bring your attention back, you can acknowledge where you went by using a silent word in your mind such as “remembering,” “thinking,” “planning.” After silently naming where your attention has been, return your attention to feeling the next breath.

4. Try to follow a full cycle of breathing: the inhale, the exhale, and the space in between the breaths. Calm yourself by allowing your mind to rest on the breath.

5. Repeat helpful phrases while breathing, such as In, Out, or Here, Calm, to support your attention as you calm the body and your breath becomes gentle and slow.

Loving-kindness Meditation

Loving-kindness meditation strengthens a generous, compassionate way of being. Shift from stress and worry to a kind, caring orientation toward yourself and others.

1. Begin with mindful breathing to calm the mind and body. You can do this in just three breaths, or take a few minutes, depending on your day.

2. Now bring to mind a loved one that you love easily and unconditionally. Fully see them in your mind’s eye, smiling at you, sending you loving wishes. Sense the positive emotions that might arise in you.

3. Offer kind wishes to your loved one. Silently repeat phrases such as

   May you be happy,

   May you be healthy,

   May you be peaceful,

   May you know that you are loved.

4. Next recall co-workers, patients, and colleagues, and send them kind wishes, repeating the same set of phrases.

5. Extend further, to the entire practice, or hospital, or industry. You can widen the circle to all living beings as you strengthen your practice. Don’t forget yourself. End with sending kind wishes to yourself and notice the effect in your own mind and body.

Practice Tip: If you notice distractions, thoughts or emotions arising during meditation, simply say silently or quietly to yourself, “This is here” or “It is what it is” and return your attention to your object of focus, whether it is your breath or the loving-kindness phrases. This phrase is a training in acceptance of whatever is here right now.

Tools for Well-Being

Try integrating mindful breathing or loving-kindness meditation into your everyday routine. Commit to 10 minutes a day for a month, in the morning, on a short break, or between patients. And don’t take it from me or the research — be your own scientist.

Tune into what you observe: a change in your emotional state; a decrease in self-focus with a shift to being oriented to others; or perhaps the associated positive feelings of well-being. Where do you feel this in your body? This shift powers an increase in empathy and compassion, which can benefit you and everyone in your practice, and in your life.

REFERENCES

1. Goleman D, Davidson RJ. Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body. New York: Avery; 2017.

2. Tang YY, Lu Q, Geng X, et al. Short-Term Meditation Induces White Matter Changes in the Anterior Cingulate. Proc Natl Acad Sci U S A. 2010;107(35):15649-15652.

3. Mrazek MD, Franklin MS, Phillips DT, Baird B, Schooler JW. Mindfulness Training Improves Working Memory Capacity and GRE Performance While Reducing Mind Wandering. Psychol Sci. 2013;24:776-781.

4. Pagnoni G, Cekic M. Age Effects on Gray Matter Volume and Attentional Performance in Zen Meditation. Neurobiol Aging. 2007;28:1623-1627.

5. Luders E, Cherbuin N, Gaser C. Estimating Brain Age Using High-Resolution Pattern Recognition: Younger Brains in Long-Term Meditation Practitioners. Neuroimage. 2016;134:508-513.

6. Buric I, Farias M, Jong J, Mee C, Brazil IA. What Is the Molecular Signature of Mind–Body Interventions? A Systematic Review of Gene Expression Changes Induced by Meditation and Related Practices. Front Immunol. 2017;8:670.

7. Rosenkranz MA, Davidson RJ, Maccoon DG, Sheridan JF, Kalin NH, Lutz A. A Comparison of Mindfulness-Based Stress Reduction and an Active Control in Modulation of Neurogenic Inflammation. Brain Behav Immun. 2013;27:174-184.

8. Blackburn E, Epel E. The Telomere Effect: A Revolutionary Approach to Living Younger, Healthier, Longer. London: Orion Spring; 2017.

9. Brewer J. The Craving Mind: From Cigarettes to Smartphones to Love – Why We Get Hooked and How We Can Break Bad Habits. New York: Yale University Press; 2017.

10. Tang YY, Tang R, Posner MI. Brief Meditation Training Induces Smoking Reduction. Proc Natl Acad Sci U S A. 2013;110:13971-13975.

11. Singer T. The Neuroscience of Compassion. Presentation at the World Economic Forum. Video, 20:00. Mar 9, 2015, youtube​.com​/watch​?v​=n​-hKS4rucTY.

12. Singer T, Klimecki O. Empathy and Compassion. Curr Biol. 2014;24(18):R875-R878. doi: 10.1016/j.cub.2014.06.054.

13. Cameron L. The Mindful Day: Practical Ways to Find Focus, Calm and Joy from Morning to Evening. Washington, DC: National Geographic; 2018.