by Rajat Chand, PGY-2, R1
John H. Stroger Jr. Hospital of Cook County
Before you read this, begin by finding a comfortable, seated position. Maintain good posture and without forcing it, allow the teeth to close. Allow all of the muscles in your body to relax.
“We human beings have been given the capacity to think, and we often think wrongly. To know how to think requires a great deal of penetration, understanding, but to know what to think is comparatively easy. Our present education consists in telling us what to think, it does not teach us how to think, how to penetrate, explore.” – Krishnamurti
I’m often curious about the “cool,” which drew me to interventional radiology. On a basic level, I’ve discovered it to mean having the knowledge of two almost completely different disciplines in medicine, which allows one to perform complex, safe procedures and develop lasting relationships with patients. This awe has helped quell my fears that it’s also an extremely difficult job. Diagnostic radiology already stands out as a field bearing an immense workload with a reported burnout rate consistently around 50%. Add to the demand of harnessing impressive clinical skills during residency, the expectation to become proficient both in diagnostic and interventional radiology over four years is almost unrealistic. Yet the best and brightest are investing in the profound impacts of the society and choosing to pursue the IR residency. It is an obligation of institutions and program directors to protect the future of the field by helping to shape the minds of its trainees in a modern and progressive manner, equipped enough to bare such skill mastery. No other field demands the equanimity Sir William Osler regarded as the “premier quality of a good physician” more than interventional radiology. He further described this quality in his seminal essay, Aequanimitas, as “coolness and presence of mind under all circumstances, calmness amid storm, and clearness of judgement in moments of grave peril.” These characteristics may be perceived as innate or untrainable. However, the practice of mindfulness and meditation addresses this specifically as an internal education of “how to think” versus an external education of “what to think.” Advocating for the empirically-supported methods of mindfulness to bolster resilience and equanimity in its trainees in the face of their daunting challenges can only contribute to the success of the new residency.
According to Jon Kabat-Zinn, creator of the University of Massachusetts Center for Mindfulness in Medicine and who is largely responsible for the scientific exploration of the topic in the West, “mindfulness” means, “paying attention in a particular way on purpose, in the present moment, and without judgement.” It has been described as the “physiology of ‘de-stress. (Figure 1)’” Likely most notable to physicians, though, is its proven ability to lower human cortisol levels, even in medical students. Moreover, though, mindfulness alters brain structure to promote self-awareness, empathy, stress, attention, sensory processing, and the offset of cognitive decline as we age. It is a key element of the modern science of resilience used to battle the sequelae of burnout, which Christina Maslach, PhD, Professor Emeritus of Psychology at UC Berkeley, describes as “… a response to chronic stressors that wear on a person over time – not acute ones such as a big event or a big change.” The sequelae of emotional exhaustion, depersonalization, negative self-evaluation, and lack of empathy have been shown to insidiously contribute to errors, adversely affected physician-patient relationship, and decrease in quality of care over one’s career. Further concerns revolve around absenteeism, poor job performance, incivility, turnover, health problems, depression, and higher costs for organizations. More traditionally implemented strategies of fostering resilience include, maintaining positive emotions during work, regulating certain emotions such as fear and anger in the workplace, discussion of coping styles, providing social support, adherence to a strict moral code, and offering physical or psychological training. Mindfulness, in its nascent stages of introduction into modern society, is another key ingredient of this recipe, which not only battles stress and burnout but can also shape how the interventionalist thinks as a clinician. It is arguably a piece of training that medical schools and residency programs have been missing for so long; that is, the direct training of the “calmness amid storm.” Ideally and simply put, a day starts and ends with mindful meditation, with or without guidance. After some practice, trainees live out their workday in a more aware, free, and engaging state of mind. One that is flexible, intentional, and realistic, as opposed to reactive and habitual. In the mindfulness world, this is conceptually described as “shifting from ‘doing mode’ to ‘being mode. (Figure 2)’” The “doing mode” can be seen as an endless stimulus-response cycle based on habitual patterns of reaction, whereas the “being mode” allows for a space in between stimulus and response that enables the individual to notice how they are internally affected by the stimulus and ultimate engage the situation with awareness and clarity. Apart from the physical and relational benefits of the practice, this mental and emotional strengthening will help deliver the types of physicians Dr. Osler described in his essay. The final characteristic of any resilient program is to have resilient role models. This relatively new, modern science has to be appreciated and advocated for by the multiple committees that make up this country’s IR residencies. In the tradition of IRs being brazen trailblazers in the field of medicine, the paradigm of the IR residency should courageously adopt daily mindfulness practice as a standard feature of its curriculum. There is no better time than now to utilize such an impactful strategy for such an intense training path and continue to set an example for medical training in general.
Figure 1. Benefits of Mindfulness Meditation
Figure 2. Shifting Between Modes
(Courtesy of Charles Freligh, Clinical Psychology Doctorate Student, EVMS)
So, how do you start? I suggest downloading “The Mindfulness App” and if this is new to you, starting with 3-5 minute guided meditations, once or twice a day. Over time, as you gain better control of your focus, longer, unguided meditations will become less challenging. “Insight Timer” is another smartphone app option that is free. Keep a log and make yourself and those around you accountable for practice. Additionally, “Mindful Practice” is a great short read by Ronald Epstein, MD, published as a Special Communication in the September, 1999 issue of JAMA. He is the author of an upcoming book entitled, “Attending,” which discusses mindfulness in medicine more in depth. Ultimately, psychologists with experience in mindfulness research should be invited into the department to implement a formal training curriculum that is compatible with the constraints of residency training and possibly gather data regarding its effectiveness in this new medical specialty.
Krishamurti, Jiddu. Think on These Things. Harper Collins, Perennial Library. 1970.
Krasner, et al. Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA. 2009 September; 302(12): 1284-1293
Shanafelt, et al. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings. 2015 December; 90(12): 1600-1613
Ariely, Dan. Disturbing Trends in Physician Burnout and Satisfaction with Work-Life Balance: Dealing with Malady Among the Nation’s Healers. Mayo Clinic Proceedings. 2015 December; 90(12): 1593-1596.
Maslach, et al. Job Burnout. Annual Review of Psychology. 2001 February; 52(1): 397-422.
Epstein, Ronald. Mindful Practice. JAMA. 1999 September; 282(9): 833-838.
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For more information and to discuss implementing a mindfulness regimen at your institution, please contact Charles Freligh (Clinical Psychology Doctorate Student, Eastern Virginia Medical School) at email@example.com.