Bridging Yoga Medicine & Western Medicine: Part IV

Part 4: Healthcare Providers as Clients

This is the fourth installment in a series of articles for yoga teachers on ideas for networking and sharing yoga practice with the healthcare community in your locale.

• In Part 1, we explored defining the types of patients you can best help and using Evidence-Based Medicine (EBM) to validate the ways in which you can support them.
• In Part 2, we looked at ways to align your services within today’s healthcare world of patient-centered care and quality improvement.
• In Part 3, we discussed awareness of self in relationship with yoga teacher colleagues and how being an industry expert can serve you and future clients. In this segment, we will investigate another potential way of approaching networking with medicine – recognizing healthcare providers as an additional community that can benefit from healing.

Doctor Heal Thyself

Chances are when you meet with the medical director of a healthcare facility and/or healthcare providers in a clinic you hope to get involved with, like many other people out there, they may not know much about yoga’s potential beyond group exercise. A large part of your time will be spent educating them. Perhaps you will use talking points you put together after reflecting upon earlier articles in this series.

Meet healthcare professionals where they are at. By using language familiar to them, you will be able to draw their cognitive interest with ease. Another crucial part of outreach to consider is experiential – simultaneously drawing them in physically, emotionally, and maybe (dare I even say it?) spiritually.

There could not be a more suitable time to reach out in this way to physicians. In the United States, the healthcare workforce is experiencing work-related stress and burnout in, what even the US Surgeon General considers, alarming proportions.

Stress and Burnout in Medicine

Defining Burnout

Characterized by: (1) emotional exhaustion, or a loss of enthusiasm for work; along with (2) feelings of cynicism or depersonalization; and (3) a decreased sense of personal accomplishment at work. Physicians and other members of the healthcare team, including medical trainees, often experience burnout as a result of continued job-related stress.

In the United States, more than half of physicians may be experiencing professional burnout. A 2014 Mayo Clinic study in partnership with the American Medical Association revealed 54% of surveyed physicians reported at least one key indicator of burnout. This is an increase from 46% in 2011¹. Although burnout affects physicians in all specialties of medicine, those on the front lines of care including emergency medicine, internal medicine, and family medicine, are at greater risk. ²

Burnout amongst physicians during residency, an inherently stressful period of medical training, is perhaps even more prevalent. Surveys among residency programs from various specialties across the US report burnout to affect up to 60% of trainees.³

Physicians are not alone in their experiences. Amongst nurses, 34% of hospital nurses and 37% of nursing home nurses report burnout, while 22% working in other settings are affected as well.⁴

The Consequences

The consequences of burnout in the healthcare workforce are multi-dimensional. Personally, the increased distress can contribute to stress-related health concerns and unhealthy coping behaviors, such as substance abuse.³ Depressive symptoms, as well as professional burnout, are strongly correlated with suicidal ideation amongst doctors.^3,5

The culture of medicine can begin to take a toll as enthusiasm in work decreases and cynicism increases, affecting professionalism and healthcare team morale. The impacts of burnout can even drive some practitioners to leave their careers altogether.³

Implications for patient care are also present as burnout has been associated with suboptimal quality of care and medical errors.³ Distress has also been reported to create poorer relationships with patients, as emotional exhaustion and depersonalization are inversely correlated with the ability to provide empathy.^3,6

Risk Factors

Though it is a blend of external and internal factors that contribute to the perfect storm where burnout in medicine can arise, studies suggest institutional characteristics are significant determinants of burnout.³

Professional and environmental characteristics like workload, Electronic Health Record (EHR) tasks, work-hours, patient volumes, relationships with colleagues, autonomy, and dissatisfaction with supervisors and organizational leadership are all contributors.^3,7 When work hours are decreased, a phenomenon called “work compression” takes over where physicians are expected to complete the same amount of administrative work while providing high-quality compassionate patient care in a shortened period of time.^1,3 Personally, conflicts in relationships, work/life balance, illness, and financial debt from educational loans are additional stressors leading to burnout.³

Today’s physicians find their souls in battle, caught between the demands of growing healthcare systems along with insurance companies, in conflict with their innate desire to truly connect with their patients in meaningful ways, building compassion and trust into the heart of the care they provide.

Protective Factors

Although many of the institutional factors described above are beyond individual control, there are personal behaviors that have been shown to be protective against burnout. These include: (1) seeking and giving social support (2) engagement in activities that help to create meaning both at work and at home; and (3) health-promoting behaviors, particularly sleep hygiene and stress management.^3,8

In a study I helped to conduct at the University of Buffalo in Buffalo, NY, resident physicians who reported no regular engagement in personal emotional and/or spiritual practices to support wellbeing were two times more likely to be emotionally exhausted when compared to residents who reported engagement.   Similarly, those who reported no physical activity were almost three times more likely to be emotionally exhausted when compared to medical residents who reported 150+ minutes of at least moderate intensity physical activity per week.⁹

Solutions: A Role for Mindfulness and Yoga in Healthcare Provider Self-Care

The wide range of factors impacting healthcare worker burnout warrants solutions that effect change at multiple levels – from broader systemic, institutional layers through professional and personal dimensions. A recent meta-analysis reveals that both individual-based and organizational strategies can lead to equally meaningful reductions in healthcare provider burnout.¹⁰

While administrators work on vital structural changes, interventions to nurture personal wellness can further support provider health and resilience. Of particular interest to yoga professionals is the role mindfulness programs have been playing to increase physicians’ awareness of burnout in its early stages and temper its effects. By encouraging engagement in self-care activities and creating meaning in the workplace, mindfulness-based programs can provide an evidence-based means for healing healthcare provider burnout.^8,10

Mindfulness trainings for healthcare professionals can include meditation and yoga to develop greater self-awareness, cognitive behavioral strategies to lower reactivity in stressful situations, mindful communication to strengthen interpersonal relationships, reflection, and discussion. Participation in a twelve-month program utilizing these elements resulted in significant reductions of burnout and mood disturbances while increasing mindfulness and empathy amongst primary care physicians both in the short and long term.¹¹

Abbreviated interventions have also been successful as evidenced by a 2013 study utilizing a weekend immersion on mindfulness followed by two evening sessions, web support, and a commitment by participants to engage in 10-20 minutes of mindful home practice. This pilot trial with primary care clinicians resulted in reductions in burnout, depression, anxiety, and stress sustained over nine months of follow-up.¹² 

How Can Yoga Professionals Get Involved?

With provider wellness finally getting some much-needed attention, the healthcare system is looking for ways to bring joy and meaning back into the practice of medicine. Given the potential for mindfulness practices to support resiliency in the healthcare workforce ^7,8,10-13, now is a great time for yoga professionals to get involved. By serving this community, you could potentially help to heal burnout at a personal level while simultaneously exposing medical professionals to the healing potential of yoga, perhaps encouraging them to consider referring more patients to the practice as well.

Here are just a few starting ideas on how you may get involved:

• Offer after-hours group classes and/or privates for healthcare professionals focused on self-care practices that enhance self-compassion and mindfulness.
• Contact a clinic, hospital, or a local managed care organization about providing a workshop on mindful movement and meditation as a professional development activity for employees. Topics to include could be:
  • Brief history and philosophy of yoga, meditation, pranayama.
  • Overview of the physiological and psychological benefits of practices.
  • Restorative and Yin yoga – benefits and contraindications.
  • Meditation and mindfulness exercises for enhancing moment-to-moment awareness and identification of unhelpful thought patterns.
  • Using self-care practices to enhance gratitude, empathy, compassion, and resilience in the workplace and at home.
• Partner with existing physician wellbeing programs or local physicians to integrate yoga into their offerings
• Medical trainees can benefit from these programs. Consider contacting local medical, nursing, and physician assistant training programs as well as Graduate Medical Education (GME) departments to provide programs for students and faculty.

If you are a healthcare professional interested in learning more about evidence-based mindfulness programs tailored to physicians, please see the Mindful Practice website for further information. 

Potential Barriers

Please note the physician community can often be quick to site the laundry list of organizational and structural changes that contribute to burnout while resisting the potential for learning new personal practices. There are strong feelings amongst doctors about the need for resiliency training, and they are not entirely wrong. Doctors likely do have a strong reserve of coping skills that have helped them succeed thus far, but resilience is not just about bouncing back.

Resilience is about maintaining personal health AND being able to adapt, change, and grow. Self-care must be nurtured to help us flourish in this way. It is not one thing versus another, internal versus external characteristics; several factors contribute to physician wellness. Hence, it is advised to partner individual-based interventions with the organization level changes.¹³

I often remind physicians I have worked with that organizational changes, though very effective, can often take a long time to implement. While we keep advocating for the necessary shifts in healthcare, mindfulness and self-care practices are things we can do right now to impact personal wellness in this moment. If it can make us happier, and doesn’t have to take too much time, why not give it a chance?

Gratitude and A Request for Sharing

Thank you to Tiffany and Yoga Medicine for giving me the opportunity to share my thoughts and experiences with our community. I would love to hear more from all of you! What are strategies that have worked for you when reaching out to the medical community? Have you provided programs for healthcare professionals? What have been your experiences?

Please email me at rashmi.bismark@gmail.com to share your thoughts, comments, and questions. I plan to put together our Yoga Medicine Community’s tips into another follow-up article – so please contact me soon! Thanks again, and hope some pieces of this series have been helpful to you. Looking forward to hearing your ideas. Namaste.

References:

1. Shanafelt T, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2016 Feb;91(2):276.
2. Shanafelt T, et al. Burnout and Satisfaction With Work-Life Balance Among Physicians Relative to the General US Population. Arch Inten Med. 2012; 172(18):1377-1385.
3. Dyrbye L and Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ.2016 Jan;50(1):132-49
4. McHugh MD et al. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs. 2011;30(2):202-210.
5. Andrew LB. Medscape: Physician Suicide. Oct 2016. http://emedicine.medscape.com/article/806779-overview#showall . Accessed Oct 26, 2016.
6. Thomas MR, Dyrbye LN, et al. How do distress and wellbeing relate to medical student empathy? A multi-center study. J Gen Intern Med.2007 Feb;22(2):177-83.
7. Bodenheimer T and Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med.2014 Nov-Dec;12(6):573-6
8. Epstein RM and Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med. 2013 Mar;88(3):301-3.
9. Ahmad I, Bismark RS, Evans TB et al. Burnout and Health Promoting Behaviors Among Medical Residents in Buffalo, NY. American College of Graduate Medical Education Annual Conference, February 2013.
10. West CP et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016 Sep 28. Epub ahead of print.
11. Krasner MS, Epstein RM et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. 2009 Sep 23;302(12):1284-93.
12. Fortney L, et al. Abbreviated Mindfulness Intervention for Job Satisfaction, Quality of Life, and Compassion in Primary Care Clinicians. Ann Fam Med. 2013 Sep; 11(5): 412–420
13. Epstein RM and Privitera MR. Doing something about physician burnout. Lancet. 2016 Sept 28. Epub ahead of print.