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Date: May 12th, 2017

Reference: Ireland et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher 2017.

Guest Skeptic: Dr. Diane Birnbaumer is a Senior Clinical Faculty at Harbor-UCLA Medical Center in Torrance, CA. She is also an Emeritus Professor of Medicine at the David Geffen School of Medicine at UCLA.

Case: A resident comes to you looking for advice. He is having trouble feeling tired, short-tempered and it is affecting his work interactions and personal sense of satisfaction with his job. You suspect he is suffering from early burnout.

Background: Burnout is certainly a hot topic, and mindfulness has hit the front pages of the New York Times and Time Magazine, putting it front and center in the public eye. Burnout was a term coined by Herbert Freudenberger in 1974 (1). There are a number of ways to define burnout but one of the most widely known is by Maslach, known for the Burnout Inventory (MBI) Score. It has three components including emotional exhaustion, depersonalization and reduced feelings of personal accomplishment (2). Some ACEP members know about the MBI as it has been available as part of the Wellness Booth at the ACEP Scientific Assembly for over 20 years.

burnout-991331_1920Physicians have reported a high level of burnout. A recent study of US physicians showed that more 50% had at least one symptom of burnout. Emergency physicians reported the highest prevalence of burnout at around 70% (3).

Burnout can have negative consequences on physicians and may lead to depression (4), suicidal ideation (5), illness (6), and increased alcohol use (7). It has also been associated with negative impacts on patient care including self-perceived medical error (8), risk of medical errors (9), and quality of care (10 and 11). Many factors are correlated with burnout during emergency medicine residency (12), and a significant concern is the number of young physicians identified as suffering from burnout early in their careers.

A systematic review and meta-analysis has been published on interventions to prevent and reduce physician burnout (13). One intervention shown to have a positive impact on reducing burnout is mindfulness-based approaches.

the-stones-263661_1280Mindfulness is paying attention to both the internal and external world, being in the present moment and being non-judgmental. Mindfulness meditation was started about 2,500 years ago by Buddha, not to cure illness but rather to end mental suffering. It spread out from Northeastern India near Nepal and eventually was discovered by the Western world in the 1,800’s with British Colonization.

There was another wave of mindfulness into the west in mid 20th Century. The Beatles were a huge part of bringing meditation and mindfulness to the West when they became practitioners. It was in 1975 that a group of individuals started the Insight Meditation Society in Massachusetts.

Then in 1979 a molecular biologist from MIT named Dr. Jon Kabat-Zinn started the Mindfulness Based Stress Reduction (MBSR) program that consisted of an 8-week course. It was first used as an adjunct to regular medical treatment for patients with chronic pain and other chronic illnesses.

Researchers have been looking at the therapeutic effects of mindfulness ever since. If you search “mindfulness meditation” in PubMed you get over 1,300 hits.

Clinical Question: Can a mindfulness program reduce stress and burnout among interns on an emergency medicine rotation?

Reference: Ireland et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Medical Teacher 2017.

  • Population: Intern doctors completing their emergency department rotation.
  • Intervention: Ten-week mindfulness training intervention
  • Comparison: One hour extra break per week
  • Outcome:

Authors’ Conclusions: “Mindfulness interventions may provide medical practitioners with skills to effectively manage stress and burnout, thereby reducing their experience of these symptoms. It is likely that doctors would benefit from the inclusion of such a training program as a part of their general medical education.”

Quality Checklist for Randomized Clinical Trials:

  1. checklistThe study population included or focused on those in the emergency department. Yes. These were medical interns doing their rotation in emergency medicine.
  2. The interns were adequately randomized. Unsure.
  3. The randomization process was concealed. Unsure.
  4. The interns were analyzed in the groups to which they were randomized. Yes. However, they did not explicitly state it was an intention-to-treat analysis.
  5. The study interns were recruited consecutively (i.e. no selection bias). Yes.
  6. The interns in both groups were similar with respect to prognostic factors. No. There were no demographics/gender given and controls started with higher stress.
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No.
  8. All groups were treated equally except for the intervention. Unsure. The control group could have been contamination through transfer of information that would have limited effect size.
  9. Follow-up was complete (i.e. at least 80% for both groups). Yes.
  10. All intern-important outcomes were considered. Unsure.
  11. The treatment effect was large enough and precise enough to be clinically significant. Unsure.

Key Results: All 44 interns (100%) agreed to be in the study. The mean age was 27 years with about 2/3 being female.

Burnout: Significant reduction with mindfulness
Stress: Significant reduction with mindfulness

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1) Randomization – They do not explain how randomization was done but rather just that “participants were randomly assigned to the intervention or control group.” So did they assign every other intern that signed up, or did they have a random number generator or some other method?

2) Blinding – Participants were not blinded to group assignment. This could have biased the study towards a positive treatment effect.

3) Similar at Base Line – We do not know if the two groups were equal at baseline for things like age or gender. Pretest conditions for experience with mediation/mindfulness, appeal of mediation/mindfulness and expectations of the potential helpfulness of mediation/mindfulness was equivalent. However, the treatment group reported higher perceived stress at baseline, which could inflate the treatment effect.

4) Treated Equal – It is unsure if both groups were treated equal except for the mindfulness intervention. The authors recognize that there could have been some contamination between the treatment group and the control group. Transfer of information may have taken place but would have decreased the effect size.

5) Effect Size – While the effect size on stress and burnout were statistically significant it is not clear if they are clinically significant. For more intern oriented-outcomes, a large sample size would be needed to check for decreases in alcohol use, drug use, depression, and suicide. It would also be very difficult to tease out “patient oriented outcomes” like medical errors in a complex health system.

Comment on authors’ conclusion compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Mindfulness meditation is something to consider when dealing with the stress of an emergency medicine rotation.

Case Resolution: The resident who was suffering early burnout had a clear and remarkable benefit from starting a daily, app-based mindfulness and meditation practice. Everyone who works with him noticed the change (without knowing why he was different), and he tells me the practice is now a vital and required part of his daily routine.

Dr. Diane Birnbaumer

Dr. Diane Birnbaumer

Clinical Application: We are not sure if it has a clinical impact at this point. More studies are needed, but a calmer and happier doctor should logically translate into a better clinical impact.

What do I tell the Resident? Thank you for letting me know you are having difficulties coping. Residency is stressful and you are not the only one who has had trouble with stress, but there are ways to mitigate the stress and stay healthy. In addition to eating well, getting enough sleep, exercising regularly and staying socially connected, mindfulness meditation may help.

Keener Kontest: Last weeks’ winner was Dr. Rachel Rowlands a paediatric emergency medicine physician from the United Kingdom. She knew a buckle (also called torus) fractures are defined as a compression of the bony cortex on one side with the opposite cortex remaining intact. In contrast, a greenstick fracture the opposite cortex is not intact.

Listen to the SGEM podcast on iTunes to hear this weeks’ question. If you think you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Other FOAMed Resources:

If you are feeling like you are burning out or know someone who might be showing some signs of early burnout then reach out to them, let them know they are not alone and there are resources available that can help.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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References:

  1. Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159–65.
  2. Maslach C, Jackson SE, Leiter MP. 1986. Maslach burnout inventory. Palo Alto (CA): Consulting Psychologists Press.
  3. 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 Clin Proc. 2015;90(12):1600-1613
  4. Martini S, Arfken CL, Churchill A, Balon R. Burnout comparison among residents in different medical specialties. Acad Psychiatry 2004;28:240–2.
  5. Shanafelt TD, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011; 146: 54–62
  6. Lemkau JP, Purdy RR, Rafferty JP, Rudisill JR. Correlates of burnout among family practice residents. J Med Educ 1988;63:682–91.
  7. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg 2012;147:168–74.
  8. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006; 296(9):1071-1078.
  9. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6): 995-1000.
  10. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997; 44(7):1017-1022.
  11. Grol R, Mokkink H, Smits A, et al. Work satisfaction of general practitioners and the quality of patient care. Fam Pract. 1985; 2(3):128-135.
  12. Takayesu et al. Factors Associated With Burnout During Emergency Medicine Residency. AEM 2014;21:1031–1035.
  13. West et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016; 388: 2272–81.