One participant randomized to the control group mistakenly attended the active intervention class and thereafter was included in that group. MBSR indicates Mindfulness-Based Stress Reduction.
eTable. Mean Daily Practice Time and Mean Practice Days per Week
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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):e182734. doi:10.1001/jamasurg.2018.2734
Is formal mindfulness-based, stress-resilience training feasible for surgical interns at a tertiary academic center?
In this pilot randomized clinical trial of 21 surgical interns, an 8-week formal stress-resilience training course was found to be in demand and was practical, acceptable, and adaptable to this unique environment. The training was fully implemented and readily integrated into work and personal life by participants.
Formal mindfulness-based stress-resilience training is feasible among academic surgery interns who find it to be acceptable and meaningful to their training experience.
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.
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.
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.
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.
ClinicalTrials.gov identifier: NCT03141190
Experiencing joy in the practice of medicine is by no means guaranteed. Nonetheless, for many physicians, the unique bond with patients, the satisfaction of saving a life, and a profound sense of calling make the sacrifice and heartache worthwhile.1 In contrast, growing evidence of poor mental health and professional dissatisfaction suggests that the demands placed on many physicians are making joy and fulfillment harder to find. Mounting evidence shows that burnout, a metric for dissatisfaction and distress, is a growing problem within medicine.2 Burnout is a syndrome3 associated with worse physician performance,2,4,5 patient outcomes,6-9 and hospital economics.10-12 The quadruple aim of health care underscores that physician fulfillment is an important part of any sustainable reform12 and appropriately frames physician burnout and fulfillment as issues that affect everyone—not just individual clinicians.
Burnout is believed to arise from a mismatch between expectations and reality, with more than half of practicing physicians and trainees reported to experience this problem.2,13 Among general surgery residents, the prevalence of burnout is estimated at 69%14,15 and increases the odds of both overwhelming stress and distress symptoms.15 The association between overwhelming stress and burnout is concerning because extensive evidence links overwhelming stress to detrimental effects on learning, memory, decision making, and performance.16-21
A meta-analysis suggests that stress management/mindfulness interventions are effective at addressing burnout on the individual level.22 Small cohort studies and controlled trials have shown mindfulness-based interventions to be effective at reducing stress and burnout in medical students,23 primary care physicians,24 internists,25,26 and other health care professionals.27 In general surgery trainees, inherent mindfulness tendencies (shown to increase following mindfulness training),28,29 decrease the risk of burnout, overwhelming stress, and distress symptoms by 75% or more.15 This finding suggests that mindfulness tendencies may already be used, albeit unconsciously, to cope within the high-stress culture of surgery.
Mindfulness meditation training involves the cultivation of moment-to-moment awareness of thoughts, emotions, and sensations (also known as interoception),30,31 the development of nonreactivity in response to stimuli (also known as emotional regulation), and the enhancement of perspective-taking regarding oneself and others.32,33 The most scientifically studied form of mindfulness training is the secular Mindfulness-Based Stress Reduction (MBSR) developed by Jon Kabat-Zinn in the 1980s.34 Mindfulness-Based Stress Reduction is formally offered through an 8-week, codified curriculum and has been shown to decrease stress and burnout,24,25 protect executive function,35,36 and enhance performance in multiple high-stress populations.28,37
Despite such evidence, mindfulness training among surgeons has only occasionally been suggested38 or informally pursued.39 In part, there is a seeming disconnect between surgical stoicism and indefatigability and mindfulness, which is often perceived as relaxation rather than a skill to enhance resilience. Moreover, the time pressures of surgical training make additional responsibilities and new curricula seem impossible.39,40
To systematically examine the feasibility of integrating formal mindfulness training into surgical internship at a tertiary academic center, we undertook the Mindful Surgeon pilot study. Three main questions guided our work and the findings are reported here. Is there a perceived need for formal stress-resilience training in surgery residency? Is mindfulness-based training a culturally acceptable option? Can academic surgical training accommodate the addition of a formal curriculum in mindfulness meditation without compromising training or patient care?
On April 30, 2016, we contacted the incoming class of surgical interns (n = 42) by email. Twenty-three categorical and preliminary interns (13 men and 10 women, drawn from general, plastic, oral-maxillofacial, urology, otolaryngology, ophthalmology, and orthopedic surgery, as well as neurosurgery) volunteered to participate in the study. A screening questionnaire was administered and reviewed for exclusion criteria (ie, previous experience with mindfulness practice, chronic inflammatory illness, current pregnancy). Two interns were withdrawn by their parent program because of class overlap with specialty-specific didactics (no remote-viewing option) and concern for compromised education. Final sample size was 21 (50%; 13 [62%] men, 8 [38%] women) (Figure). The study was completed in December 2017. The University of California, San Francisco, Institutional Review Board approved a pilot, longitudinal, randomized clinical trial to investigate the feasibility of modified MBSR for use by surgical interns. The protocol is available in Supplement 1. The participants provided written and oral informed consent; there was no financial compensation.
Balancing for sex and subspecialty designation, we randomized participants to modified MBSR (n = 12) or an active control (n = 9) using third-party block randomization following described operationalized methods.41 We chose to use MBSR because it is secular, codified, and the most scientifically studied mindfulness-based intervention to date. The precise content of MBSR training has been described elsewhere.34 In response to the needs and concerns from trainees and leadership, some modifications to MBSR were made (Table 1). The instructor (J.M.) was formally trained in MBSR (by John Kabat-Zinn), had more than 10 000 hours of personal meditation practice, and more than 10 years of experience as an MBSR teacher. As in traditional MBSR, sessions focused on experiential training including formal (body awareness, yoga, and sitting meditation), and informal (walking meditation, transition breathing, momentary) mindfulness practices. Remaining time was filled with didactics and group activities embodying principles discussed in class. Quiz Ref IDA 2- to 3-hour “mindfulness hike” replaced the traditional day-long silent retreat.
The active control group had similar protected class time, home practice requirements, and retreat-hike format.42-44 A shared reading and listening model, emphasizing external attention,45 was used in weekly discussion of articles on topics, such as perseverance, complications, honesty, and death, exploring self-care and the ethos of surgery, in each of these contexts. Daily practice comprised any self-determined self-care activity, and the retreat hike focused on the relaxing properties of nature. For both arms, multiple outcomes measures were assessed at baseline (before the start of internship), post intervention, and at 12-month follow-up.
To evaluate feasibility, we focused on 6 dimensions—demand, implementation, practicality, acceptability, adaptation, and integration—as proposed in a published review of feasibility studies funded through the National Cancer Institute.46 These dimensions represent a framework that can be used to comprehensively evaluate the feasibility of a given intervention. For each domain in which focus groups and key interviews were used, 2 of us (C.C.L., A.O.H., or A.D.) performed content analysis of notes and audio recordings, established categories of concepts and themes, and extracted example quotations.
Demand was operationalized as the perceived need for formalized skills to cope with stress and distress in surgical residency and evaluated by comparing stress and distress (ie, mental illness and alcohol misuse) in surgery residents with published norms from age-matched peers. Moreover, in the design phase of the Mindful Surgeon program, we held a focus group with 8 laboratory residents (after postgraduate year 3) to discuss perceptions of need, timing, and intervention content.
Implementation was operationalized as the manner in which our intervention could be fully executed within the unique culture of surgery and was evaluated by assessing interest and perceived barriers through key informant interviews with chairs and program directors from all 8 surgical departments involved in the study. Established concepts and themes served as guides for program adaptation. In addition, the study principal investigator (C.C.L.) observed weekly classes to document content delivered.
Practicality was operationalized as the costs (time and money) associated with the program and evaluated by analyzing notes from multiple strategic planning meetings with administrative, residency program, and site directors. Changes required to provide protected time for intern participation were monitored. Class attendance was taken. Frequency and duration of daily home practice were recorded via text message. Cost was evaluated by creating a cost report for personnel, space, and materials.
Acceptability was operationalized as perceived appropriateness and subjective satisfaction and evaluated with the Credibility and Expectancy Questionnaire (CEQ),45,47 which measures confidence in an intervention as a combination of cognitive credibility and affective expectancy. The CEQ comprises 6 questions rated on a scale of 0 to 10 or 0% to 100%. The first 3 questions evaluate rationale credibility and the last 3 measure treatment expectancy. Participants completed the CEQ at week 2 (after course introduction) and after week 8 (at course completion). Satisfaction was evaluated through in-class discussions and at a debriefing focus group held at study’s end.
Adaptation was operationalized as modifications made to MBSR to accommodate the unique demands and culture of surgical training and evaluated by recording changes made to traditional MBSR during planning meetings with our instructor. Meetings focused on accommodating surgery-specific scheduling and stressors while maintaining the potency of MBSR. The resultant curriculum was outlined before intervention and any changes were noted following each class.
Integration was operationalized as participant use of training skills outside of class and during follow-up and assessed by evaluating postintervention long-term practice through biweekly texts soliciting time spent and type of practices used. Both in class and during the debrief focus group, we asked for any available examples of incorporating skills personally and professionally.
Daily practice time per week and days per week practiced were examined to evaluate the ability of interns to accommodate daily home practice and the association between effort (intervention) and practice frequency and magnitude. Data are reported as group means (SD), comparing the number of days and time per day for each week of the study. Differences between groups at each week were evaluated by 2-sample, independent t tests, and P values were calculated with α level set at <.05. All calculations were done using Excel 2016 (Microsoft Inc).
The intervention group (n = 12), aged 24 to 31 years, included 5 women (42%). The control group (n = 9), aged 27 to 33 years, included 3 women (33%) (Table 2).
Local and national surveys demonstrate 2 to 5 times higher burnout, stress, and distress symptoms in surgery residents than in the general population.15 Focus group discussion revealed a perceived need for stress-resilience training during surgical residency. Content analysis of quotations revealed recurrent themes of anger as a culturally encouraged coping strategy, the experience of highly distressing affective and behavioral changes, and an early experience of disillusionment in the absence of adequate coping skills (Table 3).
Key informant interviews with 5 program directors and 4 surgery chairs revealed uniform recognition of high burnout and distress among residents and variable interest in intervention. Themes included concern for diminished professionalism and resident well-being, the need for dissemination of evidence supporting MBSR, and trepidation regarding costs related to protected time (Table 3). Quiz Ref IDAlthough recognition of need was universal, the perceived challenges of scheduling, disrupted patient care, and value kept several departments from full participation. In response to these perceived hurdles, specific scheduling and coverage concerns were elicited from directors, administrators, and chiefs and were specifically addressed in strategic planning meetings. Regarding value, grand rounds laden with evidence of MBSR efficacy48 and feasibility (particularly in the military)49 were widely presented. No adverse patient events were reported in association with study participation. No classes were cancelled or truncated and all parts of the planned curriculum were delivered.
Through strategic planning, we capitalized on weekly time established for surgical education (per American College of Graduate Medical Education standards), which is also the day for late-start operations and grand rounds at our institution. As such, class did not affect operative experience, but precluded participants from attending morning rounds. Coordinating coverage with service chiefs and minimizing adjacent nightshifts made protected time possible. Twice, on services with 1 intern in a critical role, moonlighters were used for coverage. Regarding grand rounds, an established 8-week summer hiatus was used for 3 intern boot-camp sessions followed by 5 weeks of class. The remaining 3 weeks of class overlapped with grand rounds, which were made available online for trial participants to view at their convenience.
There was no attrition from the control or intervention group. Absences, 12 of 96 (13%) in the intervention group and 11 of 72 (15%) in the control group, were primarily due to service commitments (unstable patient status), previously scheduled vacations, or personal emergencies, with 1 absence in each group due to oversleeping. Nine participants (75%) from the intervention group and 4 individuals (44%) from the control group attended the voluntary retreat hike. Control participants had statistically significant longer daily practice time than the intervention group during 3 weeks and no significant difference in days per week of practice. Otherwise, both groups practiced similar duration and frequency on a weekly basis (eTable in Supplement 2).
Monetary costs consisted of an MBSR instructor and course materials ($4300); use of a moonlighter twice, for 2 hours (total, $400); and course materials, which included yoga mats and continental breakfast ($20/participant total). A room on campus was provided without charge.
Participants indicated similar levels of treatment expectancy and rationale credibility, as assessed by the CEQ. At week 2, expectancy was 10.28 (7.05) and 14.33 (4.21) (P = .18) and credibility was 17.28 (6.49) and 18.92 (4.87) (P = .53), respectively, for the control and intervention groups. Week 8 expectancy was 11.78 (6.00) and 18.21 (6.19) (P = .41) and credibility was 18.00 (4.24) and 20.00 (6.55) (P = .03, respectively).
Intervention participant comments during class and at the debriefing focus group revealed an overall high level of satisfaction (Table 4). Quiz Ref IDThemes included greater self-awareness and self-regulation, enhanced focus in the operating room or on-service, and improved interactions with patients and colleagues.
The original MBSR program format was modified, practically and conceptually, to accommodate the concerns of residents, program directors, and chairs revealed during the planning phases of the study (Table 1). Quiz Ref IDOn a daily basis, participants used informal practices (eg, mindful walking, scrubbing, eating, or short breathing exercises) with greater frequency than formal practice (eg, sitting meditation or body scan) at work and at home (Table 4). Practice was variably maintained a mean of 3 (.0) days per week in the follow-up year. Practice times ranged from 5 to 20 minutes, longitudinally, but 5 of 12 participants (42%) occasionally meditated for 45 minutes on days off.
This pilot randomized clinical trial demonstrates that formal mindfulness-based training is feasible and acceptable for surgical interns at a tertiary academic medical center. To address burnout and distress in medicine, institutional change is necessary. Nonetheless, such changes will take time to identify and creativity to implement. Meanwhile, individual resilience training can mitigate overwhelming stress and enhance clinicians’ ability to guide these changes.50 As with any fundamental skill-set, early nurturing increases lasting effect, yet the question remains: Why bother? It would be easier to provide a mindfulness smartphone app or an online course. To our knowledge, there has been only 1 randomized clinical trial to date comparing formal mindfulness training with a smartphone app.51 Findings suggest that smartphone apps may transiently increase self-compassion, but formal training affects perceived stress and burnout. These findings concur with those from studies of online mindfulness training, which have not been found to be as effective as formal, in-person, training.39 In line with this outcome, deeper examination of the mechanisms of mindfulness training suggests that the good feelings cultivated by popularized attention training are only a fraction of what mindfulness can deliver.52-54 The more complex skills of interoception, emotional regulation, and perspective taking, typically taught through formal training, appear to yield neurologic and cognitive changes that can enhance compassion, self-regulation, executive function, and performance.32,52,54 If these results occur, then the value of investing in formal mindfulness training is obvious. Nevertheless, before we can test for such benefits among surgeons, formal training must be deemed feasible. Our pilot study shows it to be so.
Our first finding, that demand for formal stress-resilience training exists within surgery, is supported by national data showing higher burnout, stress, and distress in general surgery trainees compared with age-matched peers. Moreover, at our institution, focus group and key interview content analysis revealed recurrent themes and concepts indicating undesirable affective and behavioral changes during residency and the desire for training to mitigate this process. Evidence supporting the value of formal cognitive training to enhance psychological well-being and/or performance comes from the military,54,55 professional sports,56,57 and, more recently, surgery.58 Although training and practice are central pillars of surgery, the explicit desire for cognitive skills training is arguably new, and therefore worth demonstrating.
Our second finding that formal mindfulness-based training is feasible during surgical internship is supported by the reasonable cost and high attendance, satisfaction, rate of home practice, and degree of integration by participants. These results reflect both the participants’ positive experience and extensive preparatory work. Building consensus and collaboration allowed us to capitalize on established infrastructure (eg, education days, late-start operations, and coverage by midlevel clinicians), which minimized conflicts and made protected participation possible.
Our third and perhaps most significant finding is that MBSR was satisfying for surgical interns, as evidenced by high attendance, committed daily practice, and subjective satisfaction. Quiz Ref IDAlthough the control group mean daily practice time was significantly higher during 3 early weeks of the course, it is worth noting that mindfulness practice is effortful,52 but control practice was relaxation. Despite the effort required, the intervention group was not deterred from practicing, even if the mean duration of daily practice was occasionally shorter. In addition, perceived logical credibility was not significantly different between groups before or after the intervention, but the expectation of efficacy was significantly higher for the intervention group at training’s end. This finding suggests that, although the control practice may have been relaxing and enjoyable, stress resilience may not have been a perceived byproduct, whereas it was in the effortful intervention.
Our fourth finding, that mindfulness skills can be effectively integrated into surgical training, is supported by the extent to which interns used mindfulness skills independently during the course and thereafter. Despite the apparent discord between conservative surgical culture and mindfulness meditation, participants expressed gratitude for the skills that they acquired and remarked how training changed their ability to manage the high-stress aspects of residency—both personal and professional. In addition, without external encouragement or incentive, participants continued to use both the formal and informal skills during the following year, suggesting that the creation of enduring healthy habits is possible.
This study has limitations, most notably the small sample comprising volunteers at a single institution with its unique issues and resources. However, our goal was to demonstrate feasibility and identify the resources and organizational factors required. Further work remains to obtain statistical power, expand to other specialties, and compare the efficacy of formal training with easier interventions with other formats, such as smartphone apps and online modules.
Although the value of formal mindfulness training has been established in other settings and populations, it remains unproven in surgery. Nevertheless, there is a growing body of literature regarding the need and desire for institutionally supported, individually focused interventions to address stress and burnout, and mindfulness-based interventions are promising in this regard.10,22,25,59Although the efficacy of formal mindfulness training remains to be proven in surgery, our study demonstrates that the necessary foundations of feasibility and acceptability are in place. With this in mind, we may find that the latest American College of Graduate Medical Education requirement for specific programming to improve resident well-being is a challenge that we can meet.
Accepted for Publication: May 13, 2017.
Corresponding Author: Carter C. Lebares, MD, Department of Surgery, University of California, San Francisco, 513 Parnassus Ave, HSW 1601, San Francisco, CA 94143 (email@example.com).
Published Online: August 29, 2018. doi:10.1001/jamasurg.2018.2734
Author Contributions: Dr Lebares had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Lebares, Mitchell, Reilly, O'Sullivan, Ascher, Harris.
Acquisition, analysis, or interpretation of data: Lebares, Hershberger, Guvva, Desai, Shen, Delucchi.
Drafting of the manuscript: Lebares, Hershberger, Guvva, Desai.
Critical revision of the manuscript for important intellectual content: Lebares, Mitchell, Shen, Reilly, Delucchi, O'Sullivan, Ascher, Harris.
Statistical analysis: Hershberger, Guvva, Desai, Delucchi.
Obtained funding: Lebares, Harris.
Administrative, technical, or material support: Lebares, Desai, Mitchell, Reilly, Harris.
Supervision: Lebares, Mitchell, Shen, Reilly, O'Sullivan, Ascher.
Conflict of Interest Disclosures: No disclosures were reported.
Funding/Support: Ms Desai was supported by National Institutes of Health grant R25#125451-03 Short Term Research Education Program to Increase Diversity in Health-Related Research.
Role of the Funder/Sponsor: The National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We acknowledge the interns who participated in this study, in particular those randomized to the control group. In addition, we thank all the surgery leadership, staff, and residents who made intern participation possible. Finally, Pamela Derish, MA (Department of Surgery, University of California, San Francisco), helped to edit this manuscript; there was no financial compensation.