Key factors for implementing mindfulness-based burnout interventions in surgery.

BACKGROUND: Burnout and distress are widespread issues in surgical training. While effective interventions are slowly coming to light, little has been published regarding the sustainable implementation of such interventions, including the critical need to identify barriers and enablers. METHODS: Enhanced Stress Resilience Training (ESRT), a mindfulness-based cognitive intervention for surgical trainees, was delivered and studied on three separate occasions. For each, focus groups, field notes, surveys and interviews were collected involving leadership, administrators and participants. Thematic analysis was used in each instance, and across instances, to explore concepts and themes, which were used to identify critical influences effecting implementation. RESULTS: Culture (surrounding the intervention), infrastructure (supporting the intervention) and adaptability (of the intervention) were repeatedly critical influences, guiding iterative adaptation of the intervention, and resulting in sustainability across groups and over time. CONCLUSIONS: Identifying critical influences on intervention feasibility and acceptability can guide intervention refinement and shift sustainable implementation barriers to become enablers, as was the case at our institution. This approach may be useful in other settings.

Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial.

Importance: Mindfulness meditation training has been shown to be feasible in surgical trainees, but affective, cognitive, and performance benefits seen in other high-stress populations have yet to be evaluated. Objective: To explore potential benefits to stress, cognition, and performance in postgraduate year 1 (PGY-1) surgery residents receiving modified mindfulness-based stress reduction (modMBSR). Design, Setting, and Participants: This follow-up study is an analysis of the Mindful Surgeon pilot randomized clinical trial of modMBSR (n = 12) vs an active control (n = 9), evaluated at baseline (T1), postintervention (T2), and 1 year (T3), took place at an academic medical center residency training program among PGY-1 surgery residents. Data were collected between June 2016 and June 2017 and analyzed from June 2017 to December 2017. Interventions: Weekly 2-hour modMBSR classes and 20 minutes of daily home practice during an 8-week period vs an active control (different content, same structure). Main Outcomes and Measures: Preliminary evidence of efficacy was explored, primarily focusing on perceived stress and executive function and secondarily on burnout, depression, motor skill performance, and changes in blood oxygen level-dependent functional neuroimaging during an emotion regulation task. Group mean scores were calculated at T1, T2, and T3 and in linear mixed-effects multivariate analysis. Effect size for analysis of covariance is presented as partial η2 with the following cutoff points: small, less than 0.06; medium, 0.06 to 0.14; large, greater than 0.14. Results: Postgraduate year 1 surgery residents (N = 21; 8 [38%] women) were randomized to a modMBSR arm (n = 12) or an active control arm (n = 9). Linear mixed-effects modeling revealed differences at T2 and T3 in perceived stress (mean [SD] difference at T2: modMBSR, 1.42 [5.74]; control, 3.44 [6.71]; η2 = 0.07; mean [SD] difference at T3: modMBSR, 1.00 [4.18]; control, 1.33 [4.69]; η2 = 0.09) and in mindfulness (mean [SD] difference at T2: modMBSR, 3.08 [3.63]; control, 1.56 [4.28]; η2 = 0.13; mean [SD] difference at T3: modMBSR, 2.17 [3.66]; control, -0.11 [6.19]; η2 = 0.15). Burnout at T2 (mean [SD] difference: modMBSR, 4.50 [9.08]; control, 3.44 [6.71]; η2 = 0.01) and T3 (mean [SD] difference: modMBSR, 5.50 [9.96]; control, 5.56 [9.69]; η2 = 0.01) showed similar increase in both groups. Working memory increased more at T2 in the modMBSR arm (mean [SD] difference, 0.35 [0.60]) than in the control arm (mean [SD] difference, 0.21 [0.74]; η2 = 0.02) and at T3 (modMBSR, 0.68 [0.69]; control, 0.26 [0.58]; η2 = 0.20). Cognitive control decreased more in the control arm at T2 (mean [SD] difference at T2: modMBSR, 0.15 [0.40]; control, -0.07 [0.32]; η2 = 0.13) and at T3 (mean [SD] difference: modMBSR, 0.07 [0.59]; control, -0.26 [0.53]; η2 = 0.16). Mean (SD) circle-cutting time improved more at T2 in the modMBSR arm (-24.08 [63.00] seconds) than in the control arm (-4.22 [112.94] seconds; η2 = 0.23) and at T3 in the modMBSR arm (-4.83 [77.94] seconds) than in the control arm (11.67 [145.17] seconds; η2 = 0.13). Blood oxygen level-dependent functional neuroimaging during an emotional regulation task showed unique postintervention activity in the modMBSR arm in areas associated with executive function control (dorsolateral prefrontal cortex) and self-awareness (precuneus). Conclusions and Relevance: In this pilot randomized clinical trial, modMBSR in PGY-1 surgery residents showed potential benefits to well-being and executive function, suggesting a powerful role for mindfulness-based cognitive training to support resident well-being and performance, as mandated by the Accreditation Council for Graduate Medical Education. Trial Registration: ClinicalTrials.gov identifier: NCT03141190.

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.

Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience.

BACKGROUND: Burnout among physicians affects mental health, performance, and patient outcomes. Surgery residency is a high-risk time for burnout. We examined burnout and the psychological characteristics that can contribute to burnout vulnerability and resilience in a group of surgical trainees. STUDY DESIGN: An online survey was distributed in September 2016 to all ACGME-accredited general surgery programs. Burnout was assessed with an abbreviated Maslach Burnout Inventory. Stress, anxiety, depression, resilience, mindfulness, and alcohol use were assessed and analyzed for prevalence. Odds ratios (ORs) were used to determine the magnitude of presumed risk and resilience factors. RESULTS: Among 566 surgical residents who participated in the survey, prevalence of burnout was 69%, equally driven by emotional exhaustion and depersonalization. Perceived stress and distress symptoms (depression, suicidal ideation, and anxiety) were notably high across training levels, but improved during lab years. Higher burnout was associated with high stress (OR 7.8; p < 0.0001), depression (OR 4.8; p < 0.0001), and suicidal ideation (OR 5.7; p < 0.0001). In contrast, dispositional mindfulness was associated with lower risk of burnout (OR 0.24; p < 0.0001), stress (OR 0.15; p < 0.0001), anxiety (OR 0.21; p < 0.0001), suicidal ideation (OR 0.25; p < 0.0001), and depression (OR 0.26; p = 0.0003). CONCLUSIONS: High levels of burnout, severe stress, and distress symptoms are experienced throughout general surgery training, with some improvement during lab years. In this cross-sectional study, trainees with burnout and high stress were at increased risk for depression and suicidal ideation. Higher dispositional mindfulness was associated with lower risk of burnout, severe stress, and distress symptoms, supporting the potential of mindfulness training to promote resilience during surgery residency.