Family Medicine Forum - FMF › wp-content › uploads › 2017 › 11 › S150_Incorpor… · Ellen Langer PhD. Mindfulness, 25th Anniversary Edition. 1989, 2014. Ronald Epstein

Family Medicine Forum

Lynn Bloom, MSW RSW

Millaray Sanchez-Campos MD, CCFP, FCFP

MHP, DIME, UGME

November 11, 2017

Montréal

familymedicine.uottawa.ca

Disclosures

No commercial conflicts

Cofounder of the University of Ottawa’s (BMRI) Academy of Mindfulness and

Contemplative Studies (M. Sanchez-Campos)

Education grants from University of Ottawa DOM and FM, DIME, CIHR

med.uOttawa.ca

Objectives: By the end of this

session, I will be able to …

Apply mindfulness practice and principles as a means of enhancing self-awareness

Recognize narrative medicine as a method of self-reflection and expression

Understand how mindfulness practice and reflective writing can support resilience


Minute of Mindfulness


“The practice of medicine is

an art, not a trade; a calling,

not a business; a calling in

which your heart will be

exercised equally with you

mind”

- Sir William Osler

“To cure sometimes,

To relieve often,

To comfort always”

- Hippocrates

The Role of the Physician


Physician/Medical Student Distress

Burnout in 47% of specialists and GP.Shanafelt et al. 2012

Medicine associated with burnout,

depression, anxiety, substance abuse,

divorce and broken relationships. Shanafelt et al. 2003

Medical Students: 27% of depression,

11% of suicidal ideation.

Rotenstein et al. Jama 2016

Medicine, The Facts


Physician Distress and Quality of

Care/Medical Errors

Of 115 responding residents, 87 (76%) met the criteria for burnout (Maslachburnout inv.)

Burnout residents were significantly more likely to self report suboptimal patient care at least monthly (53% vs. 21%; p=0.004).Shanafelt et al. Burnout and Self-Reported Patient Care in an Internal Medicine Residency

Program. Ann Inter Med. 2002; 136:358-367

Of 7905 American College Surgeons, 700 (8.9%) reported concern they had made a major error in last three months

Over 70% attributed error to individual factors

Burnout and depression were independent predictors of reporting a recent major medical error. Shanafelt et al, 2009


Mindfulness

Paying Attention

On Purpose

To Presence Moment

Experiences

With curiosity,

compassion, acceptance

MINDFULNESS

med.uOttawa.ca


What mindfulness is not…

Relaxation tool to pull out only when we are stressed

Religion

A means to an end

Accessible only after years of formal practice/ meditation

About striving, about goals, being expert meditators

A panacea for suffering

Systems we work in have responsibility for some of our suffering


Why we do what we do

We believe

If we can teach our trainees to be more mindful they will be

more attentive, fulfilled, and have a greater sense of connection

Physicians

Colleagues

Humans

– awareness, resilience, compassion within themselves and with others on a regular basis


Mindfulness Taught in

Medical Schools

Improved anxiety and depression. Goyal et al. JAMA Int. Med. 2014

Improved student well-being. Hassed et al, 2008

Moderate effect on mental distress. De Vibe et al. BMC Med. Edu. 2013

Positive effect on empathy. Ludwig, D. S., & Kabat-Zinn, J. (2008)


UGME Program

A half-day workshop delivered in their first year of clerkship

Experiential assignments to practice at home between sessions

Selected readings from a course book

Didactic, narrative and experiential components

Sessions approximately every 2 months for a total of 7 one-hour sessions throughout the two years of pre-clerkship

A 30 minute Introduction to Mindfulness lecture


Narrative Medicine


Narrative Medicine: Definition

“Medicine practiced with the narrative competency to recognize,

interpret and be moved to action by the predicament of others.”

(Charon, 2001)


Narrative Medicine

Incorporates stories into healing

the patient's story is central to care and cure

Uses stories as part of the process of understanding,

diagnosing, and treating illness using the ‘active voice’Divinsky,CFP 2007


Narrative Medicine

Four of Medicine’s Central Narrative Situations:

physician and patient

physician and self

Physician and colleagues

physicians and society

Charon, JAMA, 2001


Narrative Medicine

Two parts to Narrative Medicine:

Close reading of literature and other written text

Reflective Writing and Creative Expression


« …Writing improves

clinicians’ stories of

empathy, reflection and

courage »

« Writing that affects the reader

is art »

Rita Charon, MD, PhD

Narrative Medicine


Reflective Writing: Definition

“Reflective writing is one established method for teaching medical students

empathetic interactions with patients. Most such exercises rely on students’

reflecting upon clinical experiences. To effectively elicit, interpret, and translate

the patient's story, however, a reflective practitioner must also be self-aware,

personally and professionally.”

(DasGupta & Charon, 2004)


Reflective Writing

“Reflective writing” is more acceptable than

“creative writing”. No one wants a doctor who makes things up.”

Nellie Herman, 2017


Narrative Medicine

« Someone I cared for »


Guidelines for Reflective Writing

Confidentiality

Control over content (choose what you wish to leave in and leave out)

Write about real life, as if you were telling it to a friend

Don’t worry about grammar, spelling etc.; let it flow

Do a story with a beginning, middle and end

Peterkin, A. 2010


A. Writer reads piece to listener

B. Listener reflects to Writer on four

questions. Writer listens attentively.

1) What was the form of the piece

(poem, clinical scenario, prose, etc.)

2) What stood out or resonated for

Listener in the text?

3) Where there any images Listener

liked?

4) What was Listener curious about?

C. Listener then interviews Writer,

using the following questions:

1) What inspired your writing of the

piece?

2) Were there any surprises in the

writing process?

3) Were there challenges/struggles

you encountered in the writing of

the piece? If so, what were

they?

4) If another part or chapter were to

be added at the end, what would it

be about?

Reflective Discussion in Pairs


Now switch and repeat steps A, B and C –Listener becomes Writer,

Writer becomes Listener.

D. Debrief

How was the experience for each of you as listener and as writer?

What will you take away from this experience?


Mindful body and breath awareness


Improved

CommunicationSelf-awareness

More Empathy Wellness

Conclusions

Resilience


Thank You! ☺

Questions?

[email protected]

[email protected]


Mindfulness Resources

https://itunes.apple.com/ca/book/mindfulness-for-

medical-school/id914285826?mt=11

www.calm.com

www.mindfulselfcompassion.org

http://www.modernmeditation.ca/mindfulness-resources/

smiling mind

https://headspace

http://www.modernmeditation.ca/mindfulness-resources/

med.uOttawa.ca

Mindfulness References

Kabat-Zinn, Jon. Wherever You Go, There You Are: Mindfulness

Meditation in Everyday Life. New York: Hyperion, 1994.

Kabat-Zinn, Jon. Full Catastrophe Living. Bantam Dell. New York. 1991

Tolle, Eckhart. The Power of Now. Novato, CA: New World Library,

1999

Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B,

Mooney CJ, Quill TE. 2009. Association of an educational program in

mindful communication with burnout, empathy, and attitudes among

primary care physicians. JAMA 302(12):1284-1293.


Mindfulness References

Hanh, Thich Nhat. You Are Here. Boston: Shambhala Publications, 2001.

Daniel Barbezat and Mirabai Bush. Contemplative Practices in Higher

Education: Powerful Methods to Transform Teaching and Learning. 2014.

Ellen Langer PhD. Mindfulness, 25th Anniversary Edition. 1989, 2014.

Ronald Epstein MD. Attending. Medicine, Mindfulness and Humanity. 2016.

“Among doctors who take time for stillness, nearly all feel that the time one

makes for contemplative practices – meditation, reflection, awareness – is

soon recaptured in increased clarity. The goal of presence is not necessarily

efficiency, but efficiency often arises from presence”.


Reflective Writing References

Charon,R. Narrative Medicine: Honoring the Stories of Illness. New York:

Oxford University Press,2006.

Charon R. 2001. The patient-physician relationship. Narrative medicine: a

model for empathy, reflection, profession and trust. JAMA 286(15):1897-

1902.

DasGupta S Charon R. Personal illness narratives: using reflective writing to

teach empathy. Acad Med 2004 Apr;79(4);351-6.

Frank, A. Why doctor’s stories matter. Canadian Family Physician 2010;

56:51-57.

Peterkin A. Using reflective writing with students: ten tips. CAME Newsletter,

Special Editions: May, 2010.



Boudreau JD, Liben S, Fuks A. 2012. A faculty development workshop in

narrative-based reflective writing. Perspect Med. Educ 1(3):143-154.

Devlin MJ, Richards BF, Cunningham H, Desai U, Lewis O, Mutnick A, Nidiry

MA, Saha P, Charon R. 2015. "Where Does the Circle End?": Representation

as a critical aspect of reflection in teaching social and behavioral sciences in

medicine. Acad Psychiatry 39(6):669-677.

Herman, Nellie. Can creativity be taught? In: Charon, R DasGupta S et al.

Eds. The Principles and Practice of Narrative Medicine. New York: Oxford

University Press, 2017; 233-254.



Karkabi K, Wald HS, Cohen CO. 2014. The use of abstract paintings and

narratives to foster reflective capacity in medical educators: a multinational

faculty development workshop. Med Humanit 40(1):44-48.

Wald HS, Haramati A, Bachner YG, Urkin J. 2016. Promoting resiliency for

interprofessional faculty and senior medical students: outcomes of a

workshop using mind-body medicine and interactive reflective writing. Med

Teach 38(5):525-528.


Submission of Reflective Writing

(Remember confidentiality - either written permission or patients should not be

recognizable)

Crawford, A. et al. Eds. Ars Medica: A Journal of Medicine, The Arts and

Humanities. To contribute, check the following website: http://ars-

medica.ca/index.php/journal/login

Canadian Medical Association Journal : 750-1400 words under “Humanities

Encounters”

http://www.cmaj.ca/site/authors/preparing.xhtml#humanitiesEncounters

http://ars-medica.ca/index.php/journal/login

http://www.cmaj.ca/site/authors/preparing.xhtml


Submission of Reflective Writing

Dzwonek, A. et al. (2016) Murmurs: The Journal of Art and Healing, v.III.

University of Ottawa, Faculty of Medicine. Available at

https://murmursmag.files.wordpress.com/2016/04/murmurs-edition-3.pdf To

contribute contact: [email protected]

OMA Medical Student Publication. Scrub In.

https://www.oma.org/MEDICALSTUDENTS/Pages/ScrubIn.aspx

H.E.A.L. http://www.uottawaheal.ca Medical Students Humanities Blog,

Faculty of Medicine, University of Ottawa

mailto:[email protected]

https://www.oma.org/MEDICALSTUDENTS/Pages/ScrubIn.aspx

http://www.uottawaheal.ca/

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Family Medicine Forum - FMF › wp-content › uploads › 2017 › 11 › S150_Incorpor… · Ellen Langer PhD. Mindfulness, 25th Anniversary Edition. 1989, 2014. Ronald Epstein