Mindfulness for the Surgeon

 

                                                 

“Stimulus-independent thought” or “mind wandering” or ‘Day Dreaming’ appears to be our brains’ default mode of operation as we, human beings spend a lot of time thinking about what is not going on around us, contemplating events that happened in the past, might happen in the future, or that which may never happen at all. Its like autopilot mode, except that one can’t always count on it to take us where we intend to go. Instead, the mind takes control of our emotions resulting in a varied display of unnecessary sensations of anger, irritation, frustration, excitement, sadness, or disgust and ultimately leading to depression, anxiety, addictions and interpersonal conflicts (1). Surgeons, being human after all are no exception and do possess ‘autopilot capabilities.’ While others risk crash landing only their minds, a surgeon has potential of taking a life along with him.

Mindfulness is simply a state where the mind engages no thought or emotion and hence focuses all attention on the present moment. Mindfulness is currently defined in psychological terms as being characterized by paying total attention to the present moment with a non-judgmental awareness of the inner and/or outer experiences (2). Other stress management techniques which are more frequently adopted such as addictions and getaways aim at ‘escaping’ the issue on hand while the state of mindfulness equips you to face them and have a longer-term solution to the problems (3).

This desirable state, sometimes called a ‘flow’ experience, also refers to a period of total immersion and union with the activity being performed (4). A mindful person is in no way preventing any potential calamity but calmly accepts whatever will happen, responds to it with action rather than emotion, resulting in a relaxed mind. To give a better perspective, if a surgeon accidentally nicks a major vessel, the surgeon curses himself, thinking that he should not be making mistakes. The mind wanders to the past questioning why that happened in the first place or more frequently to the future worrying about being answerable if the animal were to die of bleeding, both of which are futile in identifying the vessel and arresting the bleeding. The wandered mind brings to the fore, an array of emotions most likely anger, disgust and frustration pointed at the assistant whose mind then starts to wander, and then the cycle repeats resulting in all the personnel in the OR succumbing to ‘pressure.’ On the other hand, a surgeon who calmly accepts the accident as part of the life of even the most skilled surgeon will be focused and unruffled and can address the major bleed more effectively, supported by an unflustered team.

Practicing mindfulness has been linked to an overall better quality of life (5,6), better quality of sleep, combating stress (7), anxiety and depression (8) and emotional exhaustion (6,9). One study evaluated mindfulness-based cognitive therapy (MBCT) over a 60-week period designed to train recovered but recurrently depressed patients to disengage from dysphoria-activated depressogenic thinking that may mediate relapse. The study reported that for patients with 3 or more previous episodes of depression, MBCT significantly reduced risk of relapse and for patients with only 2 previous episodes, MBCT did not reduce relapse (10).

A structured, 8-week, Mindfulness-Based Stress Reduction (MBSR) program on individuals infected with the human immunodeficiency virus (HIV) concluded that the results provided tentative evidence that the state of mindfulness may assist in improving immunity in individuals infected with HIV (11). Another Mindfulness-Based Stress Reduction (MBSR) program tested on Women newly diagnosed with early-stage Breast Cancer also concluded that the results provided preliminary evidence of beneficial effects of MBSR on immune function, Quality of Life, coping effectiveness and hence better treatment outcomes (12).

Many functional neuroimaging studies have demonstrated that the state of mindfulness activates the prefrontal cortex - an area of the brain associated with planning, cognitive behaviour, decision making and personality expression and attenuates responses in the amygdala - a region commonly associated with negative emotional states like fear, anger and rage (13, 14, 15).

Relevant to physicians and surgeons, one study (16) found out that mindfulness lessens the chance of physician diagnostic errors that occur due to confirmation bias (cognitive disposition which favors the pursuit of data that support a particular diagnosis over data that refute it) and anchoring bias (a resistance to adapting appropriately to subsequent data that suggest alternative diagnoses) and another concluded that it promotes better connection with patients (17).

Mindfulness for the surgeon: how to get there.

Make sure first that there are no external distractions, at least during the learning process; no disturbance should trouble you once you are familiar with the mindful state. Choose a comfortable position, make sure the body is relaxed. Take a few deep breaths, feel yourself into the lower abdomen, as it were. Become aware of the entire inner energy field of the body, slowly shift your focus from the external sensations of light and sound to your pulse, respiration, and the beating heart. By doing this, you reclaim consciousness from the mind. There will be the natural tendency of the wind to wander away with thoughts. When this happens, simply notice the distraction and return to observing your breath. Sustain that state of tranquility for as long as possible and be grateful for having those few minutes of quiet. As with any skill, it gets easier and better with practice. Gradually, the duration of experiencing mindfulness improves and you get a clearer idea of when you want to be there, how you get there and how its influencing your performance as a surgeon.

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2) Kabat-Zinn J (1994). Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. Hyperion : New York.

3) Antonio Fernando and Nathan Consedine (2014). Mindfulness for surgeons. Practical non-clinical skills for surgeons.

4) Reid D. Mindfulness and flow in occupational engagement: presence in doing. Can. J. Occup. Ther. 2011; 78: 50–6.

5) Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom. Med. 2003; 65: 571–81

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8) Hofmann S, Sawyer A, Witt A, Oh D. The effect of mindfulness-based therapy on anxiety and depression: a meta- analytic review. J. Consult. Clin. Psychol. 2010; 79: 169–83.

9) Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann. Fam. Med. September 1 2013; 11: 412–20.

10) Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol. 2000 Aug;68(4):615-23. doi: 10.1037//0022-006x.68.4.615. PMID: 10965637.

11) Robinson FP, Mathews HL, Witek-Janusek L. Psycho-endocrine-immune response to mindfulness-based stress reduction in individuals infected with the human immunodeficiency virus: a quasiexperimental study. J Altern Complement Med. 2003 Oct;9(5):683-94. doi: 10.1089/107555303322524535. PMID: 14629846.

12) Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, Durazo-Arvizu R, Mathews HL. Effect of mindfulness-based stress reduction on immune function, quality of life and coping in women newly diagnosed with early-stage breast cancer. Brain Behav Immun. 2008 Aug;22(6):969-81. doi: 10.1016/j.bbi.2008.01.012. Epub 2008 Mar 21. PMID: 18359186; PMCID: PMC2586059.

13) Creswell JD, Way BM, Eisenberger NI, Lieberman MD. Neural correlates of dispositional mindfulness during affect labeling. Psychosom Med. 2007 Jul-Aug;69(6):560-5. doi: 10.1097/PSY.0b013e3180f6171f. Epub 2007 Jul 18. PMID: 17634566.

14) Lieberman MD, Eisenberger NI, Crockett MJ, Tom SM, Pfeifer JH, Way BM. Putting feelings into words: affect labeling disrupts amygdala activity to affective stimuli. Psychol Sci 2007;18:421– 8.

15) Lieberman MD, Hariri A, Jarcho JM, Eisenberger NI, Bookheimer SY. An fMRI investigation of race-related amygdala activity in African American and Caucasian-American individuals. Nat Neurosci 2005;8: 720 –2

16) Sibinga EM, Wu AW. Clinician mindfulness and patient safety. JAMA. 2010 Dec 8;304(22):2532-3. doi: 10.1001/jama.2010.1817. PMID: 21139116

17) Beach MC, Roter D, Korthuis PT et al. A multicenter study of physician mindfulness and health care quality. Ann. Fam. Med. September 1 2013; 11: 421–8.