This article was downloaded by: [University of Colorado - Health Science Library] On: 15 December 2014, At: 06:38 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students a
b
c
d
Mert Erogul , Gary Singer , Thomas McIntyre & Dimitre G. Stefanov a
Department of Emergency Medicine, SUNY Downstate School of Medicine, Brooklyn, New York, USA b
Gary Singer, LCSW: Individual, Couples, and Group Therapy, Brooklyn, New York, USA
c
Department of Surgery, SUNY Downstate School of Medicine, Brooklyn, New York, USA
d
Click for updates
Statistical Design & Analysis, Research Division, SUNY Downstate Medical Center, Brooklyn, New York, USA Published online: 15 Oct 2014.
To cite this article: Mert Erogul, Gary Singer, Thomas McIntyre & Dimitre G. Stefanov (2014) Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students, Teaching and Learning in Medicine: An International Journal, 26:4, 350-356, DOI: 10.1080/10401334.2014.945025 To link to this article: http://dx.doi.org/10.1080/10401334.2014.945025
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(4), 350–356 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.945025
Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students Mert Erogul Department of Emergency Medicine, SUNY Downstate School of Medicine, Brooklyn, New York, USA
Gary Singer Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
Gary Singer, LCSW: Individual, Couples, and Group Therapy, Brooklyn, New York, USA
Thomas McIntyre Department of Surgery, SUNY Downstate School of Medicine, Brooklyn, New York, USA
Dimitre G. Stefanov Statistical Design & Analysis, Research Division, SUNY Downstate Medical Center, Brooklyn, New York, USA
Background: Medical students experience a high burden of stress and suffer elevated rates of depression, burnout, and suicide compared to the general population, yet there is no consensus on how to address student wellness. Purposes: The purpose of this study was to determine whether an abridged mindfulness based stress reduction (MBSR) intervention can improve measures of wellness in a randomized sample of 1st-year medical students. Methods: Fifty-eight participants were randomized to control or 8-week MBSR intervention and then invited to participate in the study. All participants were assessed using the Perceived Stress Scale (PSS), the Resilience Scale (RS), and Self-Compassion Scale (SCS) at 3 separate time points: baseline, at the conclusion of the study intervention (8 weeks), and at 6 months after the conclusion of the intervention. The intervention consisted of 75 minutes of weekly class time, suggested meditation at home, and a half-day retreat in the last week. Results: The intervention group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p = .002), 95% confidence interval (CI) [0.23, 0.92], and at 6 months (0.56, p = .001), 95% CI [0.25, 0.87]. PSS scores achieved significant reduction at the conclusion of the study (3.63, p = .03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p = .08), 95% CI [–0.37, 6.19]. The study did not demonstrate a difference in RS after the intervention, though RS was significantly correlated with both SCS and PSS. Conclusions: An abridged MBSR intervention improves perceived stress and self-compassion in 1st-year medical students and may be a valuable curricular tool to enhance wellness and professional development. Keywords
mindfulness, wellness, professionalism, balance, stress
We thank Drs. Jeffrey Greeson and Steven Rosensveig for their help in conceiving the study. Correspondence may be sent to Mert Erogul, SUNY Downstate School of Medicine, 450 Clarkson Ave., Brooklyn, NY 11203, USA. E-mail: [email protected]
INTRODUCTION Medical students comprise a highly stressed population, and stress in medical school has numerous defined consequences including depression, burnout, and suicide at levels that exceed age-matched controls.1–3 Stress in medical school may also underlie some of the attitudes of self-preservation, cynicism, and loss of compassion that shape the maladaptive professional identity.4–6 With rising rates of physician burnout,7 wellness itself is increasingly viewed as a professional competency.8,9 There is a clear rationale for preventative services and curricular tools to foster wellness and improve stress management for medical students, and whereas there have been some encouraging studies, there are as yet no agreed-upon methods to address these competencies.10,11 One promising intervention to enhance emotional well-being and psychological health is mindfulness-based stress reduction (MBSR), a well-known psychoeducational training that was developed in the late 1970s by Jon Kabat-Zinn at the University of Massachusetts Medical Center to treat patients with chronic pain.12 It has become the most widely studied method for cultivating the skill of mindfulness, which can be described as a kind of self-regulated attention characterized by nonjudgmental awareness and acceptance of internal and external stimuli.13–15 Even brief training in mindfulness has been shown to carry a spectrum of cognitive benefits that may be of value to medical students including improving cognition,16 focus, and executive attention.17 As conceived by Kabat-Zinn, the typical MBSR program lasts 8 weeks and involves 2.5 hours of class time once each week, with a day of group meditation between the 6th and 7th weeks. In addition, participants are expected to meditate at home for a certain amount of time each day—typically 40 minutes. There is evidence that abridged courses are also effective.18
350
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
351
FIG. 1. Participant recruitment.
Although initially designed for patients at an outpatient pain clinic, MBSR has been adapted for diverse populations including medical professionals and students. There is already a large body of evidence supporting the general value of MBSR and growing evidence that it can be of value to healthcare workers. It has been shown to diminish stress and improve self-compassion in clinicians,19 to reduce burnout in primary care physicians,20 and to diminish stress in medical students.21–23 Despite this evidence, it has not yet been established whether MBSR can function as a curricular tool in medical school. Much of the prior work has been done with volunteer samples, typically students taking elective courses. The exclusion of a randomized sample can be seen as a study flaw insofar as the volunteer participants represent a strong selection bias. One can also speculate that volunteer samples are less likely to include the less reflective students who might stand to benefit most from such an intervention. One recent study of mindfulness in medical students by Warnecke et al. did include a randomized group; however, the study suffered from considerable participant decay, and the intervention and control groups were not compared beyond the conclusion of the 8-week study.24 The extension of benefits beyond the period of the intervention is an important and relevant consideration. Our study aimed to determine whether a variation of the standard MBSR program (in which the 8-week schedule and retreat were maintained, but the weekly class length was reduced to 75 minutes) could help a randomized sample of 1st-year medical students in a lasting and sustained way compared to a control group. METHODS Study Design This prospective unblinded randomized controlled study was approved by the SUNY-Downstate Institutional Review Board and carried out in March of the 1st year of medical school. A sample size calculation determined that 26 participants per group would be required to detect a difference with effect size of 0.8, with a power of 80% at significance level of .05.
Participants Participants were selected at random from the 2010–2011 1st-year class of students at SUNY Downstate School of Medicine in Brooklyn, New York, by the study authors. The selection process involved using a random number generator to select students who had been numbered according to their alphabetical order in the class. This process blindly allocated 30 students to control and 30 to intervention. After this random allocation, students were asked by e-mail to consent to participate in the group to which they had been assigned. A proportion of students declined to participate (as indicated next) and were replaced by other students selected at random in a similar fashion from the remaining members of the class on a rolling basis until a complement of 30 control and 29 study participants was achieved. One study participant dropped out during the first week for scholastic reasons and his data were not used. All participants gave written consent and were paid $50 at the conclusion of the data gathering. Participants could miss no more than one of the eight sessions, and presence at the retreat (as described in the intervention) was mandatory. Participant recruitment is detailed in Figure 1. Measures Three assessment tools were used: the Perceived Stress Scale (PSS), the Self-Compassion Scale (SCS) and the Resilience Scale (RS). They have all been validated for use in this age group. The control and intervention participants were assessed using these tools at three separate times: baseline or prior to the intervention (Time 1), at the conclusion of the intervention (Time 2), and 6 months after the intervention (Time 3). Students in the two groups filled out their self-report questionnaires simultaneously in different rooms to take into consideration potentially varying stress levels related to time of the day. The PSS is a brief self-report questionnaire to measure “the degree to which individuals appraise situations in their lives as stressful.”25,26 It represents a way to assess psychological stress based on the transactional model of an individual’s ability to
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
352
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
cope with life events. It does not elicit the presence or absence of specific stressful life events (e.g., divorce, death in the family, etc.) but rather gauges the individual’s pattern of reacting to events. Our study used the 10-question short form of the PSS. The SCS is a measure of mental well-being that is associated with good psychological health. “Higher levels of selfcompassion have been associated with lower levels of depression, anxiety, maladaptive perfectionism, thought suppression, fear of failure, and egocentrism.”27 Compassion for oneself entails the ability to hold in abeyance reflexive negative judgments and therefore relates to emotional regulation. The scale measures subcategories of self-kindness, self-judgment, isolation, mindfulness, overidentification, and common humanity, the last of which relates to compassion for others. Our study used the 26-question long form of the SCS.28 The RS measures the ability to adapt and reestablish emotional equilibrium after adversity.29 As with self-compassion, resilience is a desirable and positive quality for medical students that is thought to be a state rather than a trait, meaning it is mutable in response to experience or training instead of an innate quality that is fixed and not subject to modification. The scale measures subcategories of self-reliance, meaning, equanimity, perseverance, and existential connection versus aloneness. Our study used the 14-question version of the RS. The final outcome measure was a self-report of number of minutes of meditation per day that was elicited from the intervention group at the conclusion of the program. Study Intervention The MBSR intervention involved group instruction for 75 minutes, once per week, for 8 weeks supplemented by a program of suggested meditation at home. Between the 7th and 8th weekly meeting, students attended a full-day retreat offsite as described next. The in-class sessions had two aims: first, to teach the experiential practices of mindfulness based meditation, body scan, and breathing-based yoga, and second, to provide a cognitive curriculum about understanding stress and how best to manage reactivity. These two components, the cognitive and the experiential, compose the typical MBSR program. Weekly handouts were used to illustrate concepts, and homework reflections were included. Homework included individual sessions of daily meditation for 20 minutes for the 8-week intervention. Initially these meditations started with the narrated guidance from 20-minute downloaded audio files: body scan, breath meditation, and gentle yoga. Each 20-minute track was an abbreviated version of the weekly 60-minute experience in mindfulness meditation and corresponded to the theme of the weekly meeting, reinforcing techniques used in class. After Week 4, the participants shifted from guided to self-meditation. The full-day retreat occurred offsite from 10 a.m. to 3 p.m. and had 100% attendance of the study participants. The purpose of this retreat was to immerse the participants in a full day of mindfulness, thus leveraging the experience they had gained so
TABLE 1 Baseline characteristics Totala M Age (SD) Years Female Sex n (%) M PSS-10 (SD) (0–40) M SCS-26 (SD) M RS (SD)
23.5(1.7) 26(45.6) 17.9(6.3) 3.0(0.6) 77.2(10.1)
Controlb Treatmentc p∗ 23.3(1.4) 23.6(1.9) 14(48.3) 12(42.9) 18.3(7.1) 17.6(5.5) 2.9(0.6) 3.1(0.5) 76.3(11.0) 78.1(9.1)
.56 .68 .66 .07 .50
Note: ∗ p values were determined by t test or chi-squared test as appropriate. PSS = Perceived Stress Scale; RS = Resilience Scale; SCS = Self-Compassion Scale. a N = 57. b n = 29. c n = 28.
far in the program to deepen their mindfulness practice. The instructor is a licensed psychotherapist with 35 years of regular practice in mindfulness meditation who has undergone the MBSR foundational program at the Omega Institute. Students were surveyed at the conclusion of the course as to the extent of their home meditation as part of the anonymous course evaluation. Control Group The control group did not receive any intervention during the 8-week study period.
TABLE 2 Comparison of means to published norms
PSS Baseline Poststudy Six Months Published Norm26 SCS Baseline Poststudy Six Months Published Norm30 RS-14 Baseline Poststudy Six Months Published Norm29
Control
Treatment
18.3 (7.1) 17.3 (7.7) 18.4 (6.9) 16.78 (6.86)
17.6 (5.5) 13.3 (5.1) 14.9 (6.6)
2.9 (0.6) 3.0 (0.8) 3.1 (0.6) 3.01 (0.58)
3.1 (0.5) 3.6 (0.5) 3.7 (0.53)
76.3 (11.0) 77.1 (14.1) 77.3 (12.5) 72.9 (14.2)
78.1(9.1) 80.5 (10.0) 82.4 (9.8)
Note: PSS = Perceived Stress Scale; SCS = Self-Compassion Scale; RS = Resilience Scale.
353 Self Compassion Score
Self Compassion Score
Analysis Repeated measures across time were analyzed using linear mixed models for each of the three outcomes, adjusting for age and gender. We used fixed effects for time and treatment and random effect for subject. Model-based treatment effects were calculated at the end of the study and at 6 months poststudy. T tests and chi-square tests were used to compare differences in means and proportions at baseline. All data are reported as means (standard deviations), unless otherwise specified. Pearson correlation was used to test for associations. SAS version 9.2 (SAS Institute, Cary, NC) was used for the analysis. All p values were two-sided, and p < .05 was considered statistically significant.
3.9 3.8 3.7 3.6 3.5 3.4 3.3 3.2 3.1 3.0 2.9 2.8 2.7 2.6 baseline
study conclusion
RESULTS Participant characteristics by study arm are summarized in Table 1. There were no significant differences with respect to age, sex, PSS, SCS, and RS scores at baseline. Table 2 compares both control and treatment participants to published norms which have been drawn from age-matched populations where available. At baseline, both control and treatment groups are statistically comparable to the norm. Perceived Stress Score The treatment group achieved significant reduction on PSS scores at the conclusion of the study (3.63, p = .03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p = .08), 95% CI [–0.37, 6.19] (see Figure 2). Self-Compassion Score The treatment group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p = .23), 95% CI [0.23, 0.92] and at 6 months postintervention (0.56, p = .001), 95% CI [0.25, 0.87] (see Figure 3).
Perceived Stress Score 21 20 19 18 17 16 15 14
6 mo. poststudy
time Group
Perceived Stress Score
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
Control
Treatment
FIG. 3. Self-Compassion Scale.
Resilience Score Participants in the treatment group did not achieve significantly higher scores on RS either at the conclusion of the study (3.15, p = .34), 95% CI [–3.47, 9.76), or at 6 months postintervention (4.80, p = .12), 95% CI [–1.23, 10.82] (see Figure 4). Our results show significant improvements in the study participants compared to the control group in the PSS and SCS immediately after the mindfulness training intervention. At the 6-month postintervention time point, we saw a persistence of improvement in the SCS and a nonsignificant trend toward improvement in the PSS. The intervention had no effect on the RS at either time point. Significant correlations between the outcomes existed at baseline and with regard to their change from baseline. The PSS was negatively correlated with SCS (r = –.47, p < .001), and with RS (r = –.50, p < .001) at baseline for the entire sample. The SCS and RS were positively correlated at baseline (r = .70, p < .001). There were also significant correlations between the changes in the three outcomes from baseline to 6 months poststudy in the treatment group but not in the controls. The correlation coefficients between the changes in PSS and in SCS scores were r = –.58, p = .001, in the treatment group and r = –0.35, p = .06, for the control group. Similarly, the correlation between the changes in PSS and RS scores were r = –.55, p = .003, for the treatment and r = –.37, p = .06, for the controls. Finally, a strong positive correlation was found between the changes in SCS and RS scores in the treatment group (r = .79, p < .001) and negative nonsignificant correlation (r = –.21, p = .28) in the control group (see the supplementary file).
13 12 11 baseline
study conclusion
6 mo. poststudy
time Group
Control
Treatment
FIG. 2. Perceived Stress Scale.
DISCUSSION Our study demonstrates that an abridged 8-week MBSR curriculum can reduce perceived stress and improve selfcompassion in 1st-year medical students. The beneficial effect for self-compassion persisted to 6 months postintervention, whereas the improvement of perceived stress trended to
354
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
TABLE 3 Calculated effect sizes (Cohen d) Time
SCS
PSS
RS
T2 T3
0.89 0.97
−0.62 −0.51
0.27 0.46
improvement at 6 months but was not significant. The persistence of improvement in SCS values at 6 months is notable and makes a case for the value of this intervention as a curricular tool. Although we saw no statistically significant difference in RS, there was a correlation between the RS and the other two outcome measures at both periods. Further research is required to investigate the effect of MBSR on RS, as the effect size of this relationship may be smaller than we hypothesized in our power calculation. Indeed, the calculated effect sizes (Table 3) suggest that a larger sample is needed to fully investigate the effect of MBSR on PSS and RS. The students’ baseline scores for PSS, RS, and SCS were comparable to published values for age-matched controls, as indicated in Table 2. Although the changes in SCS at 6 months were significant, the improvement in PSS did not persist to that point, though a trend was observed. This may relate to the study being underpowered (see earlier) or it may speak to what these tests are measuring—that the SCS measures beliefs about oneself or some such trait that is more amenable to stable change than is resilience or one’s relationship to stress. The beneficial effects of MBSR mirror those found in prior studies in student populations. Shapiro et al. studied a randomized population of premedical and medical students who underwent a similar 8-week mediation program and found reduced anxiety and depression, and increased empathy at the end of 8 weeks.22 Jain et al. demonstrated reductions in distress and improvements in positive mood states.31 Rosenzweig et al. found Resilience Score
Resilience Score
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
Note: SCS = Self-Compassion Scale; PSS = Perceived Stress Scale; RS = Resilience Scale.
87 86 85 84 83 82 81 80 79 78 77 76 75 74 73 72
improved total mood disturbance scores in the MBSR group compared with controls in a sample of volunteer medical students.23 Warnecke et al. demonstrated that mindfulness reduced PSS and anxiety as measured by the DASS in a randomized group of senior medical students at 8 weeks.24 Our study extended the period of observation considerably to 6 months. The effect sizes evinced in our study for SCS and PSS have been associated with positive findings relevant to medical student wellness in other published literature. Neff and McGehee32 reported mental health benefits including diminished anxiety and depression as well as greater feelings of social connectedness with effect sizes of 0.43 to 0.73 in SCS. Chang et. al.33 correlated an effect size in PSS of 0.52 after an 8-week MBSR course with a volunteer population with strong improvement in mindfulness self-efficacy and the positive states of mind scale. MBSR training has two components—a didactic classroom element and an experiential and embodied component that comes about through meditation. Although there is some meditation that takes place in class, the majority of it is designed to occur in private. There are no studies that have separated these two components and assessed their individual effectiveness. Among our study participants the mean meditation minutes per week was 40.7 (22.8), which is lower than the minimum requested commitment of 140 minutes per week in our study and far lower than the 315 minute per week commitment of the classic MBSR program. Although the students were largely enthusiastic about the intervention according to their feedback, their ability to adhere to the meditation regimen was limited because, as indicated in the feedback, many of them could not muster the requisite discipline. Given the relatively low homemeditation times in our study, we speculate that the learning that occurs as part of the classroom training may play an important role in effecting positive change. Better adherence to home meditation would likely have produced a more robust effect, but this will always be challenging to achieve in a medical student population given their academic burden. The improvement we witnessed in our study supports the value of using MBSR in this busy population that may not adhere to the requested schedule of home meditation. It would be interesting to see how material in a typical MBSR course (such as reducing reactivity, relationship to stress, relating to our experience with more deliberate awareness and equanimity) would function as part of the formal medical school curriculum. The strength of our findings is limited by a number of methodological features common to studies of this kind. First, the TABLE 4 Meditation time in treatment group (self-report with standard deviation)
baseline
study conclusion
6 mo. poststudy
time Group
Control
Treatment
FIG. 4. Resilience Scale.
Mean number of days of meditation per week Mean number of minutes per meditation session Mean number of minutes of meditation per week
2.8 (1.2) 14.6 (6.5) 40.7 (22.8)
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
randomization process: although all participants were randomly selected from the class to participate as control or intervention, it would have been preferable to ask them to consent to participate in the study and then randomize them to one group or the other. There remains the potential that students chose to participate because they had some preexisting allegiance to MBSR. We performed the randomization in the way that we did because we believed it would maximize participation, though admittedly introducing another potential bias. Even so, there were students who declined to participate in the study. The fact that approximately equal percentages of control and study participants opted out of the randomization is some solace, though the aforementioned selection bias still limits the generalizability of the results. Next, it must be noted that we did not have an active control that underwent any kind of intervention. Although there has been at least one mindfulness study to use a sham intervention for controls,34 that study used a much shorter study regimen (1 hour of total exposure). We remain skeptical about the credibility of a sham intervention for an 8-week course, especially in view of the pervasive and growing familiarity with mindfulness in our culture as well as the easy refutability of any sham with a simple Internet search. The fact that the study was not blinded introduces the possibility that students would manifest an effect based on suggestion and expectancy. Finally, the self-report measure querying the amount of time spent in meditation is inherently subject to recall bias. It would be interesting in subsequent studies to carefully track meditation times by daily diary entries and covary this measure with the study outcomes. Stress management skills and medical student well-being are cornerstones of professional development that are generally left to accrue from the training process itself in accordance with the apprenticeship model of education. MBSR and mindfulness training in general are promising interventions supported by a growing body of evidence that should be considered as curricular adjuncts to this end.
FUNDING The study was made possible by a grant from the Arnold P. Gold Foundation.
SUPPLEMENTAL MATERIAL Supplemental data for this article can be accessed on the publisher’s website at http://dx.doi.org/10.1080/10401334. 2014.945025.
REFERENCES 1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic Medicine. 2006;81:354–73.
355
2. Moffat KJ, McConnachie A, Ross S, Morrison JM. First-year medical student stress and coping in a problem-based learning medical curriculum. Medical Education. 2004;38:482–91. 3. Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. Journal of the American Medical Association 1988;260:2521–8. 4. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: A cohort study. Medical Education 2004;38:522–34. 5. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, et al. An empirical study of decline in empathy in medical school. Medical Education 2004;38:934–41. 6. Crandall SJ, Volk RJ, Loemker V. Medical students’ attitudes toward providing care for the underserved. Are we training socially responsible physicians? Journal of the American Medical Association 1993;269:2519–23. 7. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotil W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine. 2012;172:1377–85. 8. Dyrbye LN, Harper W, Moutier C, Durning SJ, Power DV. Multiinstitutional study exploring the impact of positive mental health on medical students’ professionalism in an era of high burnout. Academic Medicine 2012; 878:1024–31. 9. Association of American Medical Colleges. Educating doctors to provide high quality medical care. A vision for medical education in the United States. Report of the Ad Hoc Committee of Deans. Washington, DC: AAMC, 2004. Available at: https://members.aamc.org/eweb/upload/ Educating%20Doctors%20to%20Provide%20July%202004.pdf. Accessed July 2012. 10. Shiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Academic Psychiatry 2013; 37:158–64. 11. Ball S, Bax A. Self-care in medical education: effectiveness of healthhabits interventions for first-year medical students. Academic Medicine 2002;77:911–7. 12. Kabat-Zinn J. An outpatients program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Preliminary considerations and preliminary results. General Hospital Psychology 1982;4:33–47. 13. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, et al. Mindfulness: A proposed operational definition. Clinical Psychology 2004;3:230–41. 14. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. Journal of Alternative and Complementary Medicine 2009;15:593–600. 15. Bishop S. Mindfulness: A proposed operational definition. Clinical psychology: Science and practice. 2004;11:Health Module, p. 230. 16. Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: Evidence of brief mental training. Consciousness and Cognition 2010;19:597–605. 17. Tang Y, Ma Y, Wang J, Fan Y, Feng S, Lu Q, et al. Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences 2007;104:17152–6. 18. Carmody J, Baer R. How long does a mindfulness-based stress reduction program need to be? A review of class contact hours and effect sizes for psychological distress. Journal of Clinical Psychology 2009;65:627–38. 19. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management 2005;12:164–76. 20. Krasner MS, Epstein RM, Beckman H, Suchman AJ, Chapman B, Mooney CJ, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association 2009;302:1284–93. 21. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle programme. Advanced Health Sciences Education Theory Practice 2009;14:387–98.
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
356
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
22. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine 1998;21:581–99. 23. Rosenzweig S, Reibel DK, Greeson JA, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine 2003;15:88– 92. 24. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomized controlled trial of the effects of mindfulness practice on medical student stress levels. Medical Education 2011;45:381–8. 25. Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In S. Spacapam & S. Oskamp (Eds.), The social psychology of health: Claremont Symposium on applied social psychology (pp. 31–2). Newbury Park, CA: Sage, 1988. 26. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. Journal of Applied Social Psychology 2012;42:1320–34. 27. Yarnell LM, Neff KD. (2012). Self-compassion, interpersonal conflict resolutions, and well-being. Self and Identity. Advance online publication. doi:10.1080/15298868.2011.649545.
28. Neff KD. Development and validation of a scale to measure selfcompassion. Self and Identity 2003;2:223–50. 29. Wagnild GM, Young HM. Development and psychometric evaluation of the Resilience Scale. Journal of Nursing Measurement 1993;1:165–78. 30. Neff K, Pommier E. The relationship between self-compassion and other-focused concern among college undergraduates, community adults, and practicing meditators. Self and Identity 2013;12:160–76. doi:10.1080/15298868.2011.649546. 31. Jain S, Shapiro SL, Swanick S, Roeshe SC, Mills PJ, Bell I, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine 2007;33:11–21. 32. Neff K, McGehee P. Self-compassion and psychological resilience among adolescents and young adults. Self and Identity 2010;9:225–40. 33. Chang VY, Palesh O, Caldwell R, Glasgow N, Luskin F, et al. The effects of a mindfulness-based stress reduction program on stress, mindfulness self-efficacy, and positive states of mind. Stress and Health 2004;20:141–7. 34. Zeidan F, Johnson SK, Gordon N, Goolkasian P. Effects of brief and sham mindfulness meditation on mood and cardiovascular variables. Journal of Alternative and Complementary Medicine 2010;6:867–73.
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students a
b
c
d
Mert Erogul , Gary Singer , Thomas McIntyre & Dimitre G. Stefanov a
Department of Emergency Medicine, SUNY Downstate School of Medicine, Brooklyn, New York, USA b
Gary Singer, LCSW: Individual, Couples, and Group Therapy, Brooklyn, New York, USA
c
Department of Surgery, SUNY Downstate School of Medicine, Brooklyn, New York, USA
d
Click for updates
Statistical Design & Analysis, Research Division, SUNY Downstate Medical Center, Brooklyn, New York, USA Published online: 15 Oct 2014.
To cite this article: Mert Erogul, Gary Singer, Thomas McIntyre & Dimitre G. Stefanov (2014) Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students, Teaching and Learning in Medicine: An International Journal, 26:4, 350-356, DOI: 10.1080/10401334.2014.945025 To link to this article: http://dx.doi.org/10.1080/10401334.2014.945025
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 26(4), 350–356 C 2014, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.945025
Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students Mert Erogul Department of Emergency Medicine, SUNY Downstate School of Medicine, Brooklyn, New York, USA
Gary Singer Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
Gary Singer, LCSW: Individual, Couples, and Group Therapy, Brooklyn, New York, USA
Thomas McIntyre Department of Surgery, SUNY Downstate School of Medicine, Brooklyn, New York, USA
Dimitre G. Stefanov Statistical Design & Analysis, Research Division, SUNY Downstate Medical Center, Brooklyn, New York, USA
Background: Medical students experience a high burden of stress and suffer elevated rates of depression, burnout, and suicide compared to the general population, yet there is no consensus on how to address student wellness. Purposes: The purpose of this study was to determine whether an abridged mindfulness based stress reduction (MBSR) intervention can improve measures of wellness in a randomized sample of 1st-year medical students. Methods: Fifty-eight participants were randomized to control or 8-week MBSR intervention and then invited to participate in the study. All participants were assessed using the Perceived Stress Scale (PSS), the Resilience Scale (RS), and Self-Compassion Scale (SCS) at 3 separate time points: baseline, at the conclusion of the study intervention (8 weeks), and at 6 months after the conclusion of the intervention. The intervention consisted of 75 minutes of weekly class time, suggested meditation at home, and a half-day retreat in the last week. Results: The intervention group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p = .002), 95% confidence interval (CI) [0.23, 0.92], and at 6 months (0.56, p = .001), 95% CI [0.25, 0.87]. PSS scores achieved significant reduction at the conclusion of the study (3.63, p = .03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p = .08), 95% CI [–0.37, 6.19]. The study did not demonstrate a difference in RS after the intervention, though RS was significantly correlated with both SCS and PSS. Conclusions: An abridged MBSR intervention improves perceived stress and self-compassion in 1st-year medical students and may be a valuable curricular tool to enhance wellness and professional development. Keywords
mindfulness, wellness, professionalism, balance, stress
We thank Drs. Jeffrey Greeson and Steven Rosensveig for their help in conceiving the study. Correspondence may be sent to Mert Erogul, SUNY Downstate School of Medicine, 450 Clarkson Ave., Brooklyn, NY 11203, USA. E-mail: [email protected]
INTRODUCTION Medical students comprise a highly stressed population, and stress in medical school has numerous defined consequences including depression, burnout, and suicide at levels that exceed age-matched controls.1–3 Stress in medical school may also underlie some of the attitudes of self-preservation, cynicism, and loss of compassion that shape the maladaptive professional identity.4–6 With rising rates of physician burnout,7 wellness itself is increasingly viewed as a professional competency.8,9 There is a clear rationale for preventative services and curricular tools to foster wellness and improve stress management for medical students, and whereas there have been some encouraging studies, there are as yet no agreed-upon methods to address these competencies.10,11 One promising intervention to enhance emotional well-being and psychological health is mindfulness-based stress reduction (MBSR), a well-known psychoeducational training that was developed in the late 1970s by Jon Kabat-Zinn at the University of Massachusetts Medical Center to treat patients with chronic pain.12 It has become the most widely studied method for cultivating the skill of mindfulness, which can be described as a kind of self-regulated attention characterized by nonjudgmental awareness and acceptance of internal and external stimuli.13–15 Even brief training in mindfulness has been shown to carry a spectrum of cognitive benefits that may be of value to medical students including improving cognition,16 focus, and executive attention.17 As conceived by Kabat-Zinn, the typical MBSR program lasts 8 weeks and involves 2.5 hours of class time once each week, with a day of group meditation between the 6th and 7th weeks. In addition, participants are expected to meditate at home for a certain amount of time each day—typically 40 minutes. There is evidence that abridged courses are also effective.18
350
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
351
FIG. 1. Participant recruitment.
Although initially designed for patients at an outpatient pain clinic, MBSR has been adapted for diverse populations including medical professionals and students. There is already a large body of evidence supporting the general value of MBSR and growing evidence that it can be of value to healthcare workers. It has been shown to diminish stress and improve self-compassion in clinicians,19 to reduce burnout in primary care physicians,20 and to diminish stress in medical students.21–23 Despite this evidence, it has not yet been established whether MBSR can function as a curricular tool in medical school. Much of the prior work has been done with volunteer samples, typically students taking elective courses. The exclusion of a randomized sample can be seen as a study flaw insofar as the volunteer participants represent a strong selection bias. One can also speculate that volunteer samples are less likely to include the less reflective students who might stand to benefit most from such an intervention. One recent study of mindfulness in medical students by Warnecke et al. did include a randomized group; however, the study suffered from considerable participant decay, and the intervention and control groups were not compared beyond the conclusion of the 8-week study.24 The extension of benefits beyond the period of the intervention is an important and relevant consideration. Our study aimed to determine whether a variation of the standard MBSR program (in which the 8-week schedule and retreat were maintained, but the weekly class length was reduced to 75 minutes) could help a randomized sample of 1st-year medical students in a lasting and sustained way compared to a control group. METHODS Study Design This prospective unblinded randomized controlled study was approved by the SUNY-Downstate Institutional Review Board and carried out in March of the 1st year of medical school. A sample size calculation determined that 26 participants per group would be required to detect a difference with effect size of 0.8, with a power of 80% at significance level of .05.
Participants Participants were selected at random from the 2010–2011 1st-year class of students at SUNY Downstate School of Medicine in Brooklyn, New York, by the study authors. The selection process involved using a random number generator to select students who had been numbered according to their alphabetical order in the class. This process blindly allocated 30 students to control and 30 to intervention. After this random allocation, students were asked by e-mail to consent to participate in the group to which they had been assigned. A proportion of students declined to participate (as indicated next) and were replaced by other students selected at random in a similar fashion from the remaining members of the class on a rolling basis until a complement of 30 control and 29 study participants was achieved. One study participant dropped out during the first week for scholastic reasons and his data were not used. All participants gave written consent and were paid $50 at the conclusion of the data gathering. Participants could miss no more than one of the eight sessions, and presence at the retreat (as described in the intervention) was mandatory. Participant recruitment is detailed in Figure 1. Measures Three assessment tools were used: the Perceived Stress Scale (PSS), the Self-Compassion Scale (SCS) and the Resilience Scale (RS). They have all been validated for use in this age group. The control and intervention participants were assessed using these tools at three separate times: baseline or prior to the intervention (Time 1), at the conclusion of the intervention (Time 2), and 6 months after the intervention (Time 3). Students in the two groups filled out their self-report questionnaires simultaneously in different rooms to take into consideration potentially varying stress levels related to time of the day. The PSS is a brief self-report questionnaire to measure “the degree to which individuals appraise situations in their lives as stressful.”25,26 It represents a way to assess psychological stress based on the transactional model of an individual’s ability to
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
352
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
cope with life events. It does not elicit the presence or absence of specific stressful life events (e.g., divorce, death in the family, etc.) but rather gauges the individual’s pattern of reacting to events. Our study used the 10-question short form of the PSS. The SCS is a measure of mental well-being that is associated with good psychological health. “Higher levels of selfcompassion have been associated with lower levels of depression, anxiety, maladaptive perfectionism, thought suppression, fear of failure, and egocentrism.”27 Compassion for oneself entails the ability to hold in abeyance reflexive negative judgments and therefore relates to emotional regulation. The scale measures subcategories of self-kindness, self-judgment, isolation, mindfulness, overidentification, and common humanity, the last of which relates to compassion for others. Our study used the 26-question long form of the SCS.28 The RS measures the ability to adapt and reestablish emotional equilibrium after adversity.29 As with self-compassion, resilience is a desirable and positive quality for medical students that is thought to be a state rather than a trait, meaning it is mutable in response to experience or training instead of an innate quality that is fixed and not subject to modification. The scale measures subcategories of self-reliance, meaning, equanimity, perseverance, and existential connection versus aloneness. Our study used the 14-question version of the RS. The final outcome measure was a self-report of number of minutes of meditation per day that was elicited from the intervention group at the conclusion of the program. Study Intervention The MBSR intervention involved group instruction for 75 minutes, once per week, for 8 weeks supplemented by a program of suggested meditation at home. Between the 7th and 8th weekly meeting, students attended a full-day retreat offsite as described next. The in-class sessions had two aims: first, to teach the experiential practices of mindfulness based meditation, body scan, and breathing-based yoga, and second, to provide a cognitive curriculum about understanding stress and how best to manage reactivity. These two components, the cognitive and the experiential, compose the typical MBSR program. Weekly handouts were used to illustrate concepts, and homework reflections were included. Homework included individual sessions of daily meditation for 20 minutes for the 8-week intervention. Initially these meditations started with the narrated guidance from 20-minute downloaded audio files: body scan, breath meditation, and gentle yoga. Each 20-minute track was an abbreviated version of the weekly 60-minute experience in mindfulness meditation and corresponded to the theme of the weekly meeting, reinforcing techniques used in class. After Week 4, the participants shifted from guided to self-meditation. The full-day retreat occurred offsite from 10 a.m. to 3 p.m. and had 100% attendance of the study participants. The purpose of this retreat was to immerse the participants in a full day of mindfulness, thus leveraging the experience they had gained so
TABLE 1 Baseline characteristics Totala M Age (SD) Years Female Sex n (%) M PSS-10 (SD) (0–40) M SCS-26 (SD) M RS (SD)
23.5(1.7) 26(45.6) 17.9(6.3) 3.0(0.6) 77.2(10.1)
Controlb Treatmentc p∗ 23.3(1.4) 23.6(1.9) 14(48.3) 12(42.9) 18.3(7.1) 17.6(5.5) 2.9(0.6) 3.1(0.5) 76.3(11.0) 78.1(9.1)
.56 .68 .66 .07 .50
Note: ∗ p values were determined by t test or chi-squared test as appropriate. PSS = Perceived Stress Scale; RS = Resilience Scale; SCS = Self-Compassion Scale. a N = 57. b n = 29. c n = 28.
far in the program to deepen their mindfulness practice. The instructor is a licensed psychotherapist with 35 years of regular practice in mindfulness meditation who has undergone the MBSR foundational program at the Omega Institute. Students were surveyed at the conclusion of the course as to the extent of their home meditation as part of the anonymous course evaluation. Control Group The control group did not receive any intervention during the 8-week study period.
TABLE 2 Comparison of means to published norms
PSS Baseline Poststudy Six Months Published Norm26 SCS Baseline Poststudy Six Months Published Norm30 RS-14 Baseline Poststudy Six Months Published Norm29
Control
Treatment
18.3 (7.1) 17.3 (7.7) 18.4 (6.9) 16.78 (6.86)
17.6 (5.5) 13.3 (5.1) 14.9 (6.6)
2.9 (0.6) 3.0 (0.8) 3.1 (0.6) 3.01 (0.58)
3.1 (0.5) 3.6 (0.5) 3.7 (0.53)
76.3 (11.0) 77.1 (14.1) 77.3 (12.5) 72.9 (14.2)
78.1(9.1) 80.5 (10.0) 82.4 (9.8)
Note: PSS = Perceived Stress Scale; SCS = Self-Compassion Scale; RS = Resilience Scale.
353 Self Compassion Score
Self Compassion Score
Analysis Repeated measures across time were analyzed using linear mixed models for each of the three outcomes, adjusting for age and gender. We used fixed effects for time and treatment and random effect for subject. Model-based treatment effects were calculated at the end of the study and at 6 months poststudy. T tests and chi-square tests were used to compare differences in means and proportions at baseline. All data are reported as means (standard deviations), unless otherwise specified. Pearson correlation was used to test for associations. SAS version 9.2 (SAS Institute, Cary, NC) was used for the analysis. All p values were two-sided, and p < .05 was considered statistically significant.
3.9 3.8 3.7 3.6 3.5 3.4 3.3 3.2 3.1 3.0 2.9 2.8 2.7 2.6 baseline
study conclusion
RESULTS Participant characteristics by study arm are summarized in Table 1. There were no significant differences with respect to age, sex, PSS, SCS, and RS scores at baseline. Table 2 compares both control and treatment participants to published norms which have been drawn from age-matched populations where available. At baseline, both control and treatment groups are statistically comparable to the norm. Perceived Stress Score The treatment group achieved significant reduction on PSS scores at the conclusion of the study (3.63, p = .03), 95% CI [0.37, 6.89], but not at 6 months poststudy (2.91, p = .08), 95% CI [–0.37, 6.19] (see Figure 2). Self-Compassion Score The treatment group achieved significant increase on SCS scores both at the conclusion of the study (0.58, p = .23), 95% CI [0.23, 0.92] and at 6 months postintervention (0.56, p = .001), 95% CI [0.25, 0.87] (see Figure 3).
Perceived Stress Score 21 20 19 18 17 16 15 14
6 mo. poststudy
time Group
Perceived Stress Score
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
Control
Treatment
FIG. 3. Self-Compassion Scale.
Resilience Score Participants in the treatment group did not achieve significantly higher scores on RS either at the conclusion of the study (3.15, p = .34), 95% CI [–3.47, 9.76), or at 6 months postintervention (4.80, p = .12), 95% CI [–1.23, 10.82] (see Figure 4). Our results show significant improvements in the study participants compared to the control group in the PSS and SCS immediately after the mindfulness training intervention. At the 6-month postintervention time point, we saw a persistence of improvement in the SCS and a nonsignificant trend toward improvement in the PSS. The intervention had no effect on the RS at either time point. Significant correlations between the outcomes existed at baseline and with regard to their change from baseline. The PSS was negatively correlated with SCS (r = –.47, p < .001), and with RS (r = –.50, p < .001) at baseline for the entire sample. The SCS and RS were positively correlated at baseline (r = .70, p < .001). There were also significant correlations between the changes in the three outcomes from baseline to 6 months poststudy in the treatment group but not in the controls. The correlation coefficients between the changes in PSS and in SCS scores were r = –.58, p = .001, in the treatment group and r = –0.35, p = .06, for the control group. Similarly, the correlation between the changes in PSS and RS scores were r = –.55, p = .003, for the treatment and r = –.37, p = .06, for the controls. Finally, a strong positive correlation was found between the changes in SCS and RS scores in the treatment group (r = .79, p < .001) and negative nonsignificant correlation (r = –.21, p = .28) in the control group (see the supplementary file).
13 12 11 baseline
study conclusion
6 mo. poststudy
time Group
Control
Treatment
FIG. 2. Perceived Stress Scale.
DISCUSSION Our study demonstrates that an abridged 8-week MBSR curriculum can reduce perceived stress and improve selfcompassion in 1st-year medical students. The beneficial effect for self-compassion persisted to 6 months postintervention, whereas the improvement of perceived stress trended to
354
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
TABLE 3 Calculated effect sizes (Cohen d) Time
SCS
PSS
RS
T2 T3
0.89 0.97
−0.62 −0.51
0.27 0.46
improvement at 6 months but was not significant. The persistence of improvement in SCS values at 6 months is notable and makes a case for the value of this intervention as a curricular tool. Although we saw no statistically significant difference in RS, there was a correlation between the RS and the other two outcome measures at both periods. Further research is required to investigate the effect of MBSR on RS, as the effect size of this relationship may be smaller than we hypothesized in our power calculation. Indeed, the calculated effect sizes (Table 3) suggest that a larger sample is needed to fully investigate the effect of MBSR on PSS and RS. The students’ baseline scores for PSS, RS, and SCS were comparable to published values for age-matched controls, as indicated in Table 2. Although the changes in SCS at 6 months were significant, the improvement in PSS did not persist to that point, though a trend was observed. This may relate to the study being underpowered (see earlier) or it may speak to what these tests are measuring—that the SCS measures beliefs about oneself or some such trait that is more amenable to stable change than is resilience or one’s relationship to stress. The beneficial effects of MBSR mirror those found in prior studies in student populations. Shapiro et al. studied a randomized population of premedical and medical students who underwent a similar 8-week mediation program and found reduced anxiety and depression, and increased empathy at the end of 8 weeks.22 Jain et al. demonstrated reductions in distress and improvements in positive mood states.31 Rosenzweig et al. found Resilience Score
Resilience Score
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
Note: SCS = Self-Compassion Scale; PSS = Perceived Stress Scale; RS = Resilience Scale.
87 86 85 84 83 82 81 80 79 78 77 76 75 74 73 72
improved total mood disturbance scores in the MBSR group compared with controls in a sample of volunteer medical students.23 Warnecke et al. demonstrated that mindfulness reduced PSS and anxiety as measured by the DASS in a randomized group of senior medical students at 8 weeks.24 Our study extended the period of observation considerably to 6 months. The effect sizes evinced in our study for SCS and PSS have been associated with positive findings relevant to medical student wellness in other published literature. Neff and McGehee32 reported mental health benefits including diminished anxiety and depression as well as greater feelings of social connectedness with effect sizes of 0.43 to 0.73 in SCS. Chang et. al.33 correlated an effect size in PSS of 0.52 after an 8-week MBSR course with a volunteer population with strong improvement in mindfulness self-efficacy and the positive states of mind scale. MBSR training has two components—a didactic classroom element and an experiential and embodied component that comes about through meditation. Although there is some meditation that takes place in class, the majority of it is designed to occur in private. There are no studies that have separated these two components and assessed their individual effectiveness. Among our study participants the mean meditation minutes per week was 40.7 (22.8), which is lower than the minimum requested commitment of 140 minutes per week in our study and far lower than the 315 minute per week commitment of the classic MBSR program. Although the students were largely enthusiastic about the intervention according to their feedback, their ability to adhere to the meditation regimen was limited because, as indicated in the feedback, many of them could not muster the requisite discipline. Given the relatively low homemeditation times in our study, we speculate that the learning that occurs as part of the classroom training may play an important role in effecting positive change. Better adherence to home meditation would likely have produced a more robust effect, but this will always be challenging to achieve in a medical student population given their academic burden. The improvement we witnessed in our study supports the value of using MBSR in this busy population that may not adhere to the requested schedule of home meditation. It would be interesting to see how material in a typical MBSR course (such as reducing reactivity, relationship to stress, relating to our experience with more deliberate awareness and equanimity) would function as part of the formal medical school curriculum. The strength of our findings is limited by a number of methodological features common to studies of this kind. First, the TABLE 4 Meditation time in treatment group (self-report with standard deviation)
baseline
study conclusion
6 mo. poststudy
time Group
Control
Treatment
FIG. 4. Resilience Scale.
Mean number of days of meditation per week Mean number of minutes per meditation session Mean number of minutes of meditation per week
2.8 (1.2) 14.6 (6.5) 40.7 (22.8)
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
ABRIDGED MINDFULNESS INTERVENTION
randomization process: although all participants were randomly selected from the class to participate as control or intervention, it would have been preferable to ask them to consent to participate in the study and then randomize them to one group or the other. There remains the potential that students chose to participate because they had some preexisting allegiance to MBSR. We performed the randomization in the way that we did because we believed it would maximize participation, though admittedly introducing another potential bias. Even so, there were students who declined to participate in the study. The fact that approximately equal percentages of control and study participants opted out of the randomization is some solace, though the aforementioned selection bias still limits the generalizability of the results. Next, it must be noted that we did not have an active control that underwent any kind of intervention. Although there has been at least one mindfulness study to use a sham intervention for controls,34 that study used a much shorter study regimen (1 hour of total exposure). We remain skeptical about the credibility of a sham intervention for an 8-week course, especially in view of the pervasive and growing familiarity with mindfulness in our culture as well as the easy refutability of any sham with a simple Internet search. The fact that the study was not blinded introduces the possibility that students would manifest an effect based on suggestion and expectancy. Finally, the self-report measure querying the amount of time spent in meditation is inherently subject to recall bias. It would be interesting in subsequent studies to carefully track meditation times by daily diary entries and covary this measure with the study outcomes. Stress management skills and medical student well-being are cornerstones of professional development that are generally left to accrue from the training process itself in accordance with the apprenticeship model of education. MBSR and mindfulness training in general are promising interventions supported by a growing body of evidence that should be considered as curricular adjuncts to this end.
FUNDING The study was made possible by a grant from the Arnold P. Gold Foundation.
SUPPLEMENTAL MATERIAL Supplemental data for this article can be accessed on the publisher’s website at http://dx.doi.org/10.1080/10401334. 2014.945025.
REFERENCES 1. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Academic Medicine. 2006;81:354–73.
355
2. Moffat KJ, McConnachie A, Ross S, Morrison JM. First-year medical student stress and coping in a problem-based learning medical curriculum. Medical Education. 2004;38:482–91. 3. Clark DC, Zeldow PB. Vicissitudes of depressed mood during four years of medical school. Journal of the American Medical Association 1988;260:2521–8. 4. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: A cohort study. Medical Education 2004;38:522–34. 5. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, et al. An empirical study of decline in empathy in medical school. Medical Education 2004;38:934–41. 6. Crandall SJ, Volk RJ, Loemker V. Medical students’ attitudes toward providing care for the underserved. Are we training socially responsible physicians? Journal of the American Medical Association 1993;269:2519–23. 7. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotil W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine. 2012;172:1377–85. 8. Dyrbye LN, Harper W, Moutier C, Durning SJ, Power DV. Multiinstitutional study exploring the impact of positive mental health on medical students’ professionalism in an era of high burnout. Academic Medicine 2012; 878:1024–31. 9. Association of American Medical Colleges. Educating doctors to provide high quality medical care. A vision for medical education in the United States. Report of the Ad Hoc Committee of Deans. Washington, DC: AAMC, 2004. Available at: https://members.aamc.org/eweb/upload/ Educating%20Doctors%20to%20Provide%20July%202004.pdf. Accessed July 2012. 10. Shiralkar MT, Harris TB, Eddins-Folensbee FF, Coverdale JH. A systematic review of stress-management programs for medical students. Academic Psychiatry 2013; 37:158–64. 11. Ball S, Bax A. Self-care in medical education: effectiveness of healthhabits interventions for first-year medical students. Academic Medicine 2002;77:911–7. 12. Kabat-Zinn J. An outpatients program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Preliminary considerations and preliminary results. General Hospital Psychology 1982;4:33–47. 13. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, et al. Mindfulness: A proposed operational definition. Clinical Psychology 2004;3:230–41. 14. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. Journal of Alternative and Complementary Medicine 2009;15:593–600. 15. Bishop S. Mindfulness: A proposed operational definition. Clinical psychology: Science and practice. 2004;11:Health Module, p. 230. 16. Zeidan F, Johnson SK, Diamond BJ, David Z, Goolkasian P. Mindfulness meditation improves cognition: Evidence of brief mental training. Consciousness and Cognition 2010;19:597–605. 17. Tang Y, Ma Y, Wang J, Fan Y, Feng S, Lu Q, et al. Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences 2007;104:17152–6. 18. Carmody J, Baer R. How long does a mindfulness-based stress reduction program need to be? A review of class contact hours and effect sizes for psychological distress. Journal of Clinical Psychology 2009;65:627–38. 19. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management 2005;12:164–76. 20. Krasner MS, Epstein RM, Beckman H, Suchman AJ, Chapman B, Mooney CJ, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association 2009;302:1284–93. 21. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle programme. Advanced Health Sciences Education Theory Practice 2009;14:387–98.
Downloaded by [University of Colorado - Health Science Library] at 06:38 15 December 2014
356
M. EROGUL, G. SINGER, T. McINTYRE, D. G. STEFANOV
22. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine 1998;21:581–99. 23. Rosenzweig S, Reibel DK, Greeson JA, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teaching and Learning in Medicine 2003;15:88– 92. 24. Warnecke E, Quinn S, Ogden K, Towle N, Nelson MR. A randomized controlled trial of the effects of mindfulness practice on medical student stress levels. Medical Education 2011;45:381–8. 25. Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In S. Spacapam & S. Oskamp (Eds.), The social psychology of health: Claremont Symposium on applied social psychology (pp. 31–2). Newbury Park, CA: Sage, 1988. 26. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. Journal of Applied Social Psychology 2012;42:1320–34. 27. Yarnell LM, Neff KD. (2012). Self-compassion, interpersonal conflict resolutions, and well-being. Self and Identity. Advance online publication. doi:10.1080/15298868.2011.649545.
28. Neff KD. Development and validation of a scale to measure selfcompassion. Self and Identity 2003;2:223–50. 29. Wagnild GM, Young HM. Development and psychometric evaluation of the Resilience Scale. Journal of Nursing Measurement 1993;1:165–78. 30. Neff K, Pommier E. The relationship between self-compassion and other-focused concern among college undergraduates, community adults, and practicing meditators. Self and Identity 2013;12:160–76. doi:10.1080/15298868.2011.649546. 31. Jain S, Shapiro SL, Swanick S, Roeshe SC, Mills PJ, Bell I, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine 2007;33:11–21. 32. Neff K, McGehee P. Self-compassion and psychological resilience among adolescents and young adults. Self and Identity 2010;9:225–40. 33. Chang VY, Palesh O, Caldwell R, Glasgow N, Luskin F, et al. The effects of a mindfulness-based stress reduction program on stress, mindfulness self-efficacy, and positive states of mind. Stress and Health 2004;20:141–7. 34. Zeidan F, Johnson SK, Gordon N, Goolkasian P. Effects of brief and sham mindfulness meditation on mood and cardiovascular variables. Journal of Alternative and Complementary Medicine 2010;6:867–73.
