Spinning Plates: The art of professionalism in modern medicine

1. Spinning Plates:The art of professionalism in modern medicine Summer Institute July 2014 University of Oklahoma School of Community Medicine

2. How do we develop?What is systems-based practice?What is a humanistic professional? Jennifer K. Clark, MD

4. We are most fulfilled when the basic outer expressions of ourselves—Work, Play, and Love—are developed in such a way…. WORK Self LOVE PLAY …that together they create one cohesive narrative. (E. Erickson)

5. Self: To identify and cultivate…. Self Your Why

6. OK…. but what does this have to do with Professionalism in Medicine??

7. Work: The struggle… • Shifting context of medical practice • Artisan/Vocational to Humanistic Professional • The concept of professionalism as an expression of teachable behaviors rather than character trait or virtue. • What then is the expectation of having basic core values to enter the profession? • Practice and teaching professionalism… • The lynchpin of the hidden curriculum

8. 2 Domains Professionalism Framework 4 core values Integrity Respect Compassion Social Justice and Excellence in Care • Individual interactions • With patients/families • With colleagues • Organizational behaviors • Healthcare settings • Advocacy and professional organizations Lesser et al., JAMA, 2010

9. “One way of defining the character of clinicians is to examine their moment-to-moment actions…These small actions, cumulatively, describe the clinician as a practitioner and moral agent” -Ron Epstein, MD Professionalism: it’s a relational thing

10. Crucial conversations and confrontations: the demonstrable acts professionalism: Self-Community & Regulatory Self-Organization Self-Team Self-Patient Self-Personhood Professionalism: Behavioral skills developed from core values that are demonstrated in the interactions between professionals as well as between professionals and organizations. Community & Regulatory Organization Team Self Patient Advocacy: the intersect of work, play, and love

11. Be All that You Can Be…. Practicing Professionalism

12. Self: To identify and cultivate…. -Lesser et al -Epstein et al ADAPTIVE CAPACITY Self-awareness Interpersonal skills Intention of healing

13. Self relative to Others • Recognize it’s an everyday thing • Self-reflect….explicitly • Offer your narratives • Practice mindfulness • Expose the hidden curriculum • Demonstrate intolerance to unprofessionalism

14. Self relative to Organization • As members of organizations, reflect on your current environments… • Are you engendering a system where you or others are forced to be unprofessional?

16. What Do You Do When the Stuff Hits the Fan?Mindfulness as Self-Care for the Carer Steve Hoppes, Ph.D.

17. What is mindfulness? “Mindfulness means moment-to-moment nonjudgmental awareness.” Jon Kabat-Zinn (2011, p. 231) “Mindfulness is the energy that helps you be fully present with whatever is there.” ThichNhatHanh (2002, p. 51)

18. Therapeutic effects of mindfulness meditation Effective in reducing anxiety, depression, panic symptoms, mood disturbances, chronic pain, and stress. (Brown & Ryan, 2003; Kabat-Zinn et al., 1992; Minor et al., 2006; Teasdale, et al., 2000) Reductions were maintained in 3-month & 3-year follow-ups. (Kabat-Zinn et al., 1992; Miller et al, 1995.)

19. Therapeutic effects, continued Mindfulness training resulted in improved immune function, even in patients with HIV. (Siegel, 2011) Mindfulness training resulted in enhanced self-compassion. (Germer & Neff, 2013). Mindfulness has been shown to be effective in treating conditions such as obsessive-compulsive disorder, borderline personality disorder, and drug addiction. (Witkiewitz& Bowen, 2010; Siegel, 2011)

20. Richard Davidsonon neuroplasticity • “ … meditation can produce increases in relative left-sided anterior activation that are associated with reductions in anxiety and negative affect and increases in positive affect.” (Davidson, et al., 2003) http://www.youtube.com/watch?v=gJ1_Bmx7QdY&feature=related

21. Mindfulness & Medical Education(Rosenzweigh, Reibel, Greeson, & Brainard , 2003) • 302 Jefferson Medical College students. • Over 10 weeks, students trained in mindfulness experienced decreased Total Mood Disturbances (TMD) (p=0.05), including • Decreased anxiety (p=0.009), confusion (p=0.009), and depression (p=0.09), while increasing vigor (p=0.006). • Control group: Increased TMD (p<0.0001), anxiety (p<0.0001), confusion (p=0.02),, and depression (p = 0.06), while vigor (p<0.0001) decreased.

22. Physicians & Mindfulness In a study of 30 primary care physicians, brief mindfulness training was associated with reductions in indicators of job burnout, depression, anxiety, and stress(Fortney et al., 2013).

23. Mindfulness leads to … • Presence • “Our true home is not in the past. Our true home is not in the future. Our true home is in the here and now.” ThichNhatHanh • Equanimity • Open-heartedness • Connectedness • “We are here to awaken from our illusion of separateness.” ThichNhatHanh

24. Ram Dass • "I help people as a way to work on myself, and I work on myself to help people."

25. References Brown, K.W., & Ryan, R.M. (2003).  The benefits of being present:  Mindfulness and its role in psychological well-being.  Journal of personality and social psychology, 84, 822-848. Hanh, T.N. (2002). Be free where you are. Berkeley, CA: Parallax Press. Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M. A., Muller, D., Santorelli, S. F., Urbanowski, F., Harrington, A., Bonus, K., & Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564-570. Fortney, L., et al. (2013). Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. Annals of Family Medicine, 11, 412-420. Germer, C. K., & Neff, K. D. (2013). Self‐compassion in clinical practice. Journal Of Clinical Psychology, 69(8), Kabat-Zinn, J. (2005). Coming to our senses. NY: Hyperion.

26. References, continued Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K.E., Pbert, L., Lenderking, W.R., & Santorelli, S.F. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–43. Miller, J.J., Fletcher, K.E., and Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General Hospital Psychiatry, 17,192–200. Rosenzweig, Reibel, Greeson, Brainard, & Hojat. (2003). Mindfulness based stress reduction lowers psychological distress in medical students. Teaching & Learning in Medicine, 15, 88-92.

27. References, continued Siegel, D. (2011). The proven benefits of mindfulness. In B. Boyce (Ed.), The Mindfulness Revolution, pp. 136-139, Boston: Shambhala. Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness based cognitive therapy.  Journal of Consulting and Clinical Psychology, 68, 615-623. Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78, 362-374.