Samuel Cohen-Tanugi, MD

AAOS Now

Published 9/27/2021
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Samuel Cohen-Tanugi, MD; Ramon Jimenez, MD, FAAOS

What’s the Big Deal with Mindfulness?

Mindfulness training pivots from solving burnout to achieving peak performance

Mindfulness is becoming a hot topic and has garnered attention from virtually every corner of society, from early childhood education to military training. In recent years, mindfulness has even caught on among physicians and surgeons.

Unfortunately, the interest in mindfulness within medicine is driven primarily by alarming levels of burnout, attrition, and suicidal ideation among the healthcare workforce. Burnout is not the focus of this article, but it is important to understand why a practice long associated with Eastern spirituality is now gaining momentum as a potentially useful tool for surgeons.

Samuel Cohen-Tanugi, MD
Ramon Jimenez, MD, FAAOS

The burnout epidemic

Rates of burnout among surgical residents and orthopaedic residents have been reported in excess of 50 percent. A recent Medscape survey of U.S. physicians found that orthopaedic surgeons have the second highest rate of suicidal ideation among specialties, at 18 percent of respondents. The dire consequences of the burnout epidemic within our healthcare system have been documented on a national scale and at the level of the individual clinician. A multipronged approach to this problem is necessary, requiring structural solutions and individual interventions such as resilience and mindfulness training.

While many surgeons perceive mindfulness as a strategy to combat burnout, that may be a limited perspective. To be sure, a salve for burnout is not how the late Kobe Bryant and other professional athletes conceive of the practice, how top business executives from Google or Wall Street describe its role in their professional accomplishments, or even what the military emphasizes in its own research—despite the high levels of stress soldiers face. Instead, these groups have been drawn to mindfulness through their pursuit of the highest levels of excellence, or in other words, peak performance.

What is mindfulness?

Jon Kabat-Zinn, PhD, a pioneer in the scientific study of secular mindfulness meditation, defines it as “the awareness that arises through paying attention, on purpose, to experiences in the present moment, nonjudgmentally.”

There are three components of this definition. First, “awareness”: the grounding of attention in one’s immediate present experience. Second, “nonjudgment”: the cultivation of openness, acceptance, and nonreactivity in response to what one is aware of. Third, “on purpose”: the intention to enter a state of mindfulness, as opposed to experiencing it unpredictably as a side product of an engaging activity. A state of mindfulness is a part of normal human consciousness and something any surgeon can experience, for instance, upon picking up a scalpel to make an incision.

Mindfulness practice, also called mindfulness meditation, is the practice of cultivating a higher level and frequency of mindfulness. The analogy to physical performance and skeletal muscle, which gets stronger with use, is appropriate and may explain the ease with which the practice has spread through the world of sports.

An Eastern tradition goes west

One reason physicians and surgeons may have been skeptical about the practice of mindfulness, even after it started to gain traction in other fields, concerns its origins in Eastern spirituality. Despite its transformation into a secular form, mindfulness meditation is undeniably an adaptation of a Buddhist spiritual practice. While this connection to a non-Western culture and nonscientific belief system can be off-putting to some physicians, overlooking it can feel like ignoring the proverbial “elephant in the room.”

There are two main waves that brought these fairly esoteric Asian teachings, which were reserved primarily for monastics of various Buddhist lineages, to the United States. The waves overlapped in the 1960s. First, Asian teachers directly emigrated to the West—perhaps most famously the Vietnamese Zen monk Thich Nhat Hanh. The second wave occurred when young Americans who traveled to Thailand, India, and Burma to receive several years of local instruction returned to the United States to teach what is commonly known as “insight meditation.”

Both waves led to the establishment of American centers to diffuse these teachings, which cognitive scientists and researchers subsequently secularized into a form suitable for scientific and medical communities. This work was pioneered by Dr. Kabat-Zinn, who, after obtaining a PhD in molecular biology from the Massachusetts Institute of Technology, devoted his career to a program he named Mindfulness-Based Stress Reduction (MBSR). MBSR became the prototype for mindfulness interventions studied scientifically.

The next big development was the incorporation of these practices into the mental training of professional athletes. Renowned NBA coach Phil Jackson was at the center of this movement. As head coach of the Chicago Bulls and then the Los Angeles Lakers, he hired a meditation teacher, George Mumford, a protégé of Dr. Kabat-Zinn who trained at the same centers where Dr. Kabat-Zinn had cultivated the practice.

Witnessing the success of this approach in sports, the corporate world soon followed suit, establishing the paradigm of the “corporate athlete.” This model highlights the importance of rigorous mental training to develop teachable psychological and emotional skills that are essential to succeeding in a high-stress, high-stakes work environment.

Beyond giving credibility to the practice of mindfulness, studies in these populations—professional athletes, business leadership, and the military—also highlight its immense potential to achieve peak performance, rather than simply reduce burnout.

Mindfulness training

Over the past few years, Carter Lebares, MD, and researchers at the Center for Mindfulness in Surgery at the University of California, San Francisco have begun systematically studying the effect of a novel mindfulness training program derived from MBSR on surgical residents. The group has shown that such a program is feasible and holds preliminary promise at both ends of the spectrum: preventing burnout and achieving enhanced performance. Their pilot program, called Enhanced Stress Resilience Training, has been spreading to other residencies and is being developed in a virtual format for ease of access.

In conclusion, mindfulness is not a panacea to burnout. To march forward with that mindset is problematic for several reasons.

First, it omits orthopaedic surgeons who are not burned out or who fail to recognize burnout. Second, it risks overselling the benefits of mindfulness. It is unlikely that mindfulness practice alone could cure a burnt-out physician struggling with suicidal ideation. Mindfulness’s paradigm-shifting effect is more likely to be realized if it diffuses widely throughout healthcare systems and training programs, rather than simply as a targeted intervention for at-risk clinicians.

Orthopedic surgeons strive for excellence. Mindfulness appears to have benefitted societal heroes, from superstar athletes to Special Forces soldier, in their quest for peak performance. Perhaps it is time for orthopaedic surgeons to learn from their success.

Samuel Cohen-Tanugi, MD, is a senior resident in orthopaedic surgery at Atrium Health/OrthoCarolina in Charlotte, N.C. 

Ramon Jimenez, MD, FAAOS, is a semi-retired orthopaedic surgeon of 49 years, now working as a consultant for orthopaedic medical-legal evaluations in Monterey, Calif. He was the recipient of the AAOS 2018 William W. Tipton Jr, MD, Leadership Award.

Anne D. Jimenez, LCSW, also contributed to this article.

References

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  5. Lebares CC, Hershberger AO, Guvva EV, et al: Feasibility of formal mindfulness-based stress-resilience training among surgery interns: a randomized clinical trial. JAMA Surg. 2018;153(10):1-8.
  6. Lebares CC, Coaston TN, Delucchi KL, et al. Enhanced stress resilience training in surgeons: iterative adaptation and biopsychosocial effects in 2 small randomized trials. Ann Surg. 2021;273(3):424-32.