Mindfulness for surgeons

Mental training in general surgery: a qualitative review of Australian trainee perceptions

BACKGROUND

Mental training is the cognitive process and pedagogical technique of 'viewing' and 'feeling' a task without physically performing it. Its application is well-established within aviation, elite sports and the arts. While surgical trainees often mentally rehearse prior to operating, this technique is yet to be established for educational and skill acquisition purposes. The aim of this study was to investigate trainee awareness of mental training, the use of mental rehearsal, and explore perceived benefits and barriers to its implementation.

METHODS

An exploratory qualitative study design was employed, with semi-structured interviews of general surgical trainees across Australia. Interviews were transcribed and thematic analysis undertaken to identify common themes.

RESULTS

A total of 10 General Surgery trainees were interviewed encompassing each Australian state and territory. A consistent finding was that all teaching of operative skills occurs in the clinical environment, without the adjunct of structured practical or cognitive simulation. All trainees reported mentally rehearsing procedures in some capacity as part of personal preparation, and were supportive of implementing formal mental training for surgical skill development. Themes included standardization of training, enhancing training during times of reduced clinical exposure, minimizing anxiety, and improving communication. Implementation was deemed to be most effective through a bank of online mental training resources.

CONCLUSION

Mental training was supported by General Surgical trainees, with perceived potential benefits in multiple domains. To mitigate the main perceived barrier of time constraints, an online method of delivery was felt to be optimal.

To Err is human, but what happens when surgeons Err?

BACKGROUND

Physicians involved in adverse events may suffer from second victim syndrome and can experience emotional and physical distress long after the complication occurred. We sought determine the prevalence of second victim syndrome among surgeons at our children's hospital and evaluate any differences in how surgeons respond to adverse events based on their age, position, and gender.

METHODS

An anonymous 19-question questionnaire distributed via institutional emails linking to an anonymous Research Electronic Data Capture (REDCap) survey. Eligible participants included all surgeons and rotating surgical trainees at our hospital.

RESULTS

Of 64 faculty surgeons eligible to participate, 63 surveys were returned for a 98% completion rate. Ten additional surveys from surgical trainees were completed for a total of 73 participants. Eighty-four percent reported having had difficulty dealing with a poor outcome or unhappy patient/family. Speaking with a colleague was the most common coping strategy, reported by 82%. Fifty-six percent indicated they believed reporting a poor outcome would have negative ramifications for them. Younger surgeons were more likely to suppress their feelings following an adverse event, and trainees were less likely to advise their peers to speak to a superior about the event (p < 0.05).

CONCLUSION

There is a high prevalence of second victim syndrome among surgeons at our children's hospital. There exist differences in ways that surgeons respond to adverse events based on age and position. Healthcare institutions should establish formal mechanisms of support to shift the culture towards one where help is actively sought and offered.

LEVEL OF EVIDENCE

IV.

Strategies to Improve Perioperative Communication During the COVID-19 Pandemic

The coronavirus disease 2019 pandemic has led to a variety of challenges that have necessitated process changes in perioperative environments. Communication failures are a cause of surgical adverse events, and the pandemic has created additional communication concerns. Measures to prevent disease transmission, such as social distancing and wearing personal protective equipment, may inhibit communication. Relational dynamics and the types of collaboration that perioperative health care professionals exhibit can affect the quality of communication. The use of checklists during procedures and the hand‐over process may enhance communication content. Health care professionals can use communication tools, such as portable and fixed communication devices, an electronic display of the OR schedule, cyber‐physical systems, and short message service (ie, text messages) to facilitate information sharing. The concepts presented in this article should help perioperative nurses to improve communication during and after the pandemic.

A Systematic Review of Educational Interventions and Their Impact on Empathy and Compassion of Undergraduate Medical Students

Introduction: A compassionate and patient-centered care leads to improved clinical outcomes. Promoting empathy and compassion of medical students is a forerunner of their well-being, emotional stability, and a patient-centered care. However, there is slender evidence about best educational interventions that can inculcate empathy and compassion skills. Our objective was to conduct a systematic review of research evaluating the associations between spectrum, effectiveness, frequency of teaching modalities and their outcomes on compassion and empathy to highlight best practices.

Methods: We searched the Web of Science, PubMed, Scopus, and EBSCO Host on 22nd July 2020. We adapted our search strategy from a previously published systematic review on education for compassion and empathy. Selected studies were required to have used unique educational interventions for promoting empathy and compassion of medical students. The research questions were based on Participants (medical students), Intervention (empathy and/or compassion related teaching), Comparison, and Outcome.

Results: We analyzed 24 articles from the initial yield of 2,861. Twenty-two were quantitative studies with a mean of 12.8 on MERSQI. Twelve were randomized controlled trials while 5 measured outcomes with single group pre- and post-tests. There was no association found between duration, frequency and complexity of an educational intervention and its effectiveness. Twenty used multimodality curricula, and of those 18 reported statistically significant positive improvement in empathy, while 3 of 4 single modality were effective. Only three studies looked for long-term effects of educational interventions. Fourteen studies evaluated Kirkpatrick's level one (self-reported knowledge), 2 level three (behavior), and 6 level four (patient outcomes). We identified six major educational constructs of teaching empathy and compassion; communication, mindfulness, early clinical exposure, technology-enhanced learning, comics and arts and culture.

Discussion: Our review couldn't identify a standard teaching construct in place and highlighted that different teaching tools carry similar impact in promoting compassion and empathy and a sustainable program rather than a single training activity is essential.

Mindfulness in the OR: A Pilot Study Investigating the Efficacy of an Abbreviated Mindfulness Intervention on Improving Performance in the Operating Room

BACKGROUND

Surgery requires operating room physicians to succumb to unpredictable schedules, long hours, and involved operations, which have led many to acquire maladaptive habits to attain focus in the OR. Research on mindfulness in the medical community has shown positive results on stress, burnout, and quality of life. However, due to the seemingly subjective nature of the benefits of mindfulness as well as the lengthy time requirement by participants, researchers have had difficulty conducting experiments with adequate sample sizes and controls in operating room specialties.

OBJECTIVE

We assessed the hypotheses that a brief mindfulness intervention on physicians, residents, and anesthesiologists can improve mindfulness, focus, and perceived stress in the operating room. Additionally, we hypothesized that the improvement in scores are independent of level of training and physician type.

METHODS

As part of a 3 (Physician Type) X 3 (Case) X 2(Timing) factorial design, 33 surgeons, anesthesiologists, and surgical residents completed a pre- and postintervention Mindfulness Awareness and Attention Scales (MAAS) survey. Three categories of surgery cases, routine-elective, complex-elective, and add-on, were completed pre- and postintervention, along with measures addressing focus and perceived stress. The intervention included a 25-minute mindfulness training on the benefits of mindfulness and how to utilize a brief, 4-minute mindfulness skill employed prior to each postintervention surgery.

RESULTS

The mindfulness intervention was associated with a significant increase in mindfulness (p = 0.006) and flow state (p = 0.009) and a significant decrease in perceived stress (p = 0.033), particularly during the complex routine cases (p = 0.024).

CONCLUSIONS

We have developed a brief mindfulness intervention that is compatible with the busy workflow of operating room physicians and can increase the mindful state of participants as well as improve factors that are associated with burnout and distractions.

The unmeasured quality metric: Burn out and the second victim syndrome in healthcare

Physician Burn Out has become endemic as Healthcare has become increasingly complex and challenging to physicians who provide care to critically ill patients. Physicians are more prone to make errors when burnt out. Most Healthcare institutions have not been responsive to support physicians when burned out or when disturbing outcomes occur. Peer support has evolved as the preferred way to help a physician recover after the loss of a patient or a medical error. Best practices are evolving as awareness increases and better research questions arise. Individuals providers, surgical leaders and institutions can all be influential as we address this problem.

Feasibility of Formal Mindfulness-Based Stress-Resilience Training Among Surgery Interns: A Randomized Clinical Trial

Importance

Among surgical trainees, burnout and distress are prevalent, but mindfulness has been shown to decrease the risk of depression, suicidal ideation, burnout, and overwhelming stress. In other high-stress populations, formal mindfulness training has been shown to improve mental health, yet this approach has not been tried in surgery.

Objective

To test the feasibility and acceptability of modified Mindfulness-Based Stress Reduction (MBSR) training during surgical residency.

Design, Setting, and Participants

A pilot randomized clinical trial of modified MBSR vs an active control was conducted with 21 surgical interns in a residency training program at a tertiary academic medical center, from April 30, 2016, to December 2017.

Interventions

Weekly 2-hour, modified MBSR classes and 20 minutes of suggested daily home practice over an 8-week period.

Main Outcomes and Measures

Feasibility was assessed along 6 domains (demand, implementation, practicality, acceptability, adaptation, and integration), using focus groups, interviews, surveys, attendance, daily practice time, and subjective self-report of experience.

Results

Of the 21 residents included in the analysis, 13 were men (62%). Mean (SD [range]) age of the intervention group was 29.0 (2.4 [24-31]) years, and the mean (SD [range]) age of the control group was 27.4 (2.1 [27-33]) years. Formal stress-resilience training was feasible through cultivation of stakeholder support. Modified MBSR was acceptable as evidenced by no attrition; high attendance (12 of 96 absences [13%] in the intervention group and 11 of 72 absences [15%] in the control group); no significant difference in days per week practiced between groups; similar mean (SD) daily practice time between groups with significant differences only in week 1 (control, 28.15 [12.55] minutes; intervention, 15.47 [4.06] minutes; P = .02), week 2 (control, 23.89 [12.93] minutes; intervention, 12.61 [6.06] minutes; P = .03), and week 4 (control, 26.26 [13.12] minutes; intervention, 15.36 [6.13] minutes; P = .04); course satisfaction (based on interviews and focus group feedback); and posttraining-perceived credibility (control, 18.00 [4.24]; intervention, 20.00 [6.55]; P = .03). Mindfulness skills were integrated into personal and professional settings and the independent practice of mindfulness skills continued over 12 months of follow-up (mean days [SD] per week formal practice, 3 [1.0]).

Conclusions and Relevance

Formal MBSR training is feasible and acceptable to surgical interns at a tertiary academic center. Interns found the concepts and skills useful both personally and professionally and participation had no detrimental effect on their surgical training or patient care.

Trial Registration

ClinicalTrials.gov identifier: NCT03141190.

Sustaining a career in surgery

Surgery is a demanding career with great rewards and equally great challenges. In order to sustain our careers as well as the careers of our colleagues, it is important to understand and address the physical, psychological and spiritual challenges of surgery. With rare exception, the majority of surgery residents and practicing surgeons who prematurely leave surgery do so because they find the work to be physically, emotionally or spiritually incompatible with the vision they have for their life. Understanding these issues and providing solutions to improve surgeon wellness can help prevent societal loss of these highly trained professionals and suffering for surgeons and their families.

Understanding Resident Performance, Mindfulness, and Communication in Critical Care Rotations

OBJECTIVE

Evidence from the medical literature suggests that surgical trainees can benefit from mindful practices. Surgical educators are challenged with the need to address resident core competencies, some of which may be facilitated by higher levels of mindfulness. This study explores whether mindful residents perform better than their peers as members of the health care team.

DESIGN

This study employed a multiphase, multimethod design to assess resident mindfulness, communication, and clinical performance.

SETTING

Academic, tertiary medical center.

PARTICIPANTS

Residents (N = 51) working in an intensive care unit. In phase I, medical residents completed a self-report survey of mindfulness, communication, emotional affect, and clinical decision-making. In phase II, resident performance was assessed using independent ratings of mindfulness and clinical decision-making by attending physicians and registered nurses.

RESULTS

In phase 1, a significant positive relationship was found between resident performance and mindfulness, positive affect (PA), and communication. In phase 2, attending physicians/registered nurses' perceptions of residents' mindfulness were positively correlated with communication and inversely related to negative affect (NA). The top quartile of residents for performance and mindfulness had the lowest NA. Higher-rated residents underestimated their performance/mindfulness, whereas those in the lowest quartile overestimated these factors.

CONCLUSIONS

This study offers a number of implications for medical resident education. First, mindfulness was perceived to be a significant contributor to self-assessments of competency and performance. Second, both PA and NA were important to mindfulness and performance. Third, communication was associated with resident performance, mindfulness, and PA. These implications suggest that individual characteristics of mindfulness, communication, and affect, all potentially modifiable, influence care quality and safety. To improve low performers, surgical educators could screen and identify residents with inaccurate self-assessments. Residents open to feedback will improve faster and develop awareness toward situations and interactions with patients, colleagues, attending physicians, and staff.

Compassion Fatigue and Mindfulness: Comparing Mental Health Professionals and MSW Student Interns

The relationship between compassion fatigue and mindfulness in mental health professionals compared to Master of Social Work (MSW) students is explored. A convenience sample of mental health professionals (n = 40) and MSW students (n = 111) completed the Five Facet Mindfulness Questionnaire and Professional Quality of Life Scale. Results indicate a medium, negative correlation between compassion fatigue and mindfulness, with high levels of compassion fatigue associated with lower levels of mindfulness. There was no statistically significant difference between mental health workers and MSW students on the combined dependent variables. Results suggest that mindfulness protects against compassion fatigue regardless of professional or student status.