ABSTRACT
Mindfulness training positively influences residents personally and professionally. Routine integration into residency may be impacted by limited understanding of the ways in which mindfulness training enhances clinical care.
We explored residents' direct experience and personal application of mindfulness in their clinical work following 10 hours of mindfulness training.
Mindfulness training sessions were facilitated between 2017 and 2019 for 5 groups of residents: pediatrics, ophthalmology, postgraduate year (PGY)-1 anesthesiology, and 2 different years of PGY-1 family medicine residents. Training was integrated into resident protected didactic time and attendance was expected, although not mandated, with the exception of pediatrics, in which the department mandated the training. Qualitative evaluation was conducted using a voluntary, semi-structured, de-identified phone interview within 2 months post-training. Reviewers independently coded the transcripts and then dialogued to reach consensus around emergent themes.
Thirty-six of 72 residents (50%) who participated in the training completed interviews. Themes were similar across specialties. All residents acknowledged the potential usefulness of mindfulness training during residency. Six residents (17%) reported they had not applied the mindfulness training to their daily work by the end of the course. There were 4 emergent themes related to clinical application of mindfulness training: integrating brief moments of mindfulness practice, self-awareness, relational presence with patients, and maintaining perspective during clinical encounters and residency training as a whole.
After completing a 10-hour mindfulness training program, residents reported enhanced perspective-taking and relationship-building with themselves and their patients in clinical settings across medical and procedural specialties.
Introduction
Inordinately high levels of stress and burnout continue to plague the experience of graduate medical education.1-6 This circumstance has a significant negative impact on personal and interpersonal relationships in clinical care and is associated with resident suicidal ideation and self-harm.7-10
Over the past 40 years, mindfulness-based interventions have been incorporated into allopathic medicine to support patients suffering from conditions such as depression,11-14 anxiety,11,14,15 and chronic pain.14,16 These interventions were originally developed by Jon Kabat-Zinn through the 8-week Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical School.17 Since that time, a wide variety of mindfulness-based interventions have been developed, modified, and/or adapted for the graduate medical education population.18-22 All these interventions introduce mindfulness practice in which a participant may “pay attention, in the present moment, purposefully, and without judgment.”23
Initial studies using mindfulness-based interventions during residency education found associations of mindfulness training with reduced resident burnout,21,24,25 depression,21 anxiety,21 perceived stress,22 and worry,26 as well as improved self-compassion,26 resilience,24 and positive affect.27 More recent studies have assessed the impact of mindfulness training on specific clinical skills within individual specialties, finding improvements in working memory,28 empathy,29 communication,30 procedural skill efficiency,28 and simulation training performance.31 There is, however, limited information about how residents perceive the personal and interpersonal impact of mindfulness practices as they engage in clinical care.
The purpose of this program evaluation was to assess residents' perspectives on how a 10-hour multispecialty mindfulness training changed their thoughts and behaviors during clinical work. By understanding residents' experiences, we may continue to grow a body of knowledge that informs best practices for integrating mindfulness training into graduate medical education programs.
Our goal was to assess residents' perspectives of how a 10-hour multispecialty mindfulness training changed their thoughts and behaviors during clinical work.
We identified 4 major themes related to how residents noticed mindfulness training showing up in their clinical practice: brief moments, self-awareness, relational presence, and perspective-taking.
Limitations of this study include participation bias, a question of reproducibility, and a qualitative coding method that is not widely accepted.
By developing mindfulness training curricula based on resident physicians' self-identified clinical skills improvements, such training may have the potential to better serve residents and their future careers.
Methods
Setting and Participants
This study was a multispecialty, single-site program evaluation of a mindfulness-based course for residents conducted between 2017 and 2019. Graduate medical education at the University of Wisconsin (UW) School of Medicine and Public Health, where this study occurred, includes more than 75 Accreditation Council for Graduate Medical Education (ACGME)-accredited specialty and subspecialty programs.
Curricular Intervention
Supportive Training for Residency through Education in Mindfulness (STREaM) is a 10-hour mindfulness-based skills course created for first-year residents. The development and pilot data from this course have been previously described.22 Curricular content details are available on the course website.32
STREaM was first developed and piloted in 2016 with the intention of building skills to support family medicine residents through the challenges of residency education.22 The training was developed to allow for flexible integration into resident protected educational time. The STREaM curriculum used between 2017 and 2019 was revised based on feedback from our pilot study. Themes of the course included awareness and attention, practicing mindfulness “short times, many times,” uncovering our wholeness, and compassion and mindful presence in clinical practice. Each session began with a moving meditation and a seated meditation followed by a combination of self-reflection, dyad conversations, and large group dialogue. Each session closed with an invitation to continue brief mindfulness practices individually between sessions. Please review online supplementary data for full course details.
Course faculty included a UW Health Mindfulness Program manager who had trained in and taught mindfulness since 1999, a pediatric hospitalist (S.W.) who had completed MBSR training through the UW Health Mindfulness Program, and a family physician trained in integrative medicine who completed the UW Health MBSR Teaching Fellowship as well as the University of California San Diego Mindfulness Teacher Training Intensive program.
Four residency programs participated between fall 2017 and spring 2019. There were 2 cohorts from family medicine and one each from ophthalmology, anesthesiology, and pediatrics. Participants were generally first-year residents, except in ophthalmology where all residents attended. Course sessions were scheduled during protected educational time within each program. Sessions varied between 60 and 90 minutes, with all courses totaling 10 hours. The last session was generally a longer session lasting 3 to 4 hours. Participation was expected but not mandated, except the final session of the STREaM curriculum in pediatrics, which was held during a curricular block when available residents were expected to attend.
The theoretical construct that aligns most closely with the current state of the literature and the STREaM curriculum intention is outlined in Braun et al.33 The authors propose 3 potential patient care-related outcomes from mindfulness-based interventions: improved treatment outcomes, improved patient-health care professional relationship, and improved patient safety. Our program evaluation sought to assess resident physicians' perspectives on the ways in which mindfulness training may inform the patient-health care professional relationship, whether that be indirectly through greater self-awareness or directly during resident-patient interactions.
Funding for course development, facilitation, and evaluation came primarily from a University of Wisconsin-Madison School of Medicine and Public Health Department of Family Medicine and Community Health Small Grant.
Study Recruitment and Data Collection
During the last course session, residents were invited to provide contact information if they were willing to participate in a post-course interview with a non-teaching research staff (M.G.) who has experience in conducting qualitative research interviews. M.G. administered semi-structured interviews using a facilitator guide (provided as online supplementary data). M.G. was neither course faculty nor involved in any way with residents' program evaluations. Interviews were completed by phone between 2018 and 2019 and took place within 1 month of the resident's completion of the STREaM program.
Interview questions were piloted and revised based on feedback from our pilot study in 2016-2017. The primary questions that our qualitative analysis team analyzed for this study were related to how residents applied mindfulness training in clinical environments. The prompts were: “How has the training you have done ‘shown up' in your clinical practice?” “What has changed about your approach to patient care?” and “What has changed about how you interact with colleagues?” The full list of questions for the interview is in the online supplementary data. The interview guide did not change during data collection. Semi-structured interviews were audio recorded, transcribed by a research assistant, and de-identified prior to analysis. The facilitator was not known to the participants, had prior experience in conducting qualitative research interviews, and was instrumental in revising the interview questions after the pilot study. She did not have any formal training in mindfulness and had not been through medical school or residency training. The researcher who conducted the interviews contacted residents 3 times post-training to schedule interviews and did not hear back about specific reasons for nonparticipation.
Data Analysis
A 5-member team, consisting of 2 family physicians (B.B., V.M.), one pediatrician (S.W.), one senior mindfulness instructor (C.S.), and one emergency medicine fellow (C.V.), performed qualitative data analysis of the de-identified transcribed phone interviews. All except one had previous experience with qualitative analysis. The authors (V.M., S.W.) were the only 2 reviewers who had personal and professional experience in both medical education and mindfulness. Prior to starting the analysis, each member of the team underwent a reflexive bracketing process34,35 to identify their relationship with the subject material and associated biases. The complete list of bracketing questions and each reviewer's assumptions about how mindfulness affects patient care are in the online supplementary data. After completing the bracketing process, the total number of transcripts was divided into 2 groups due to the large volume of transcripts to be reviewed. We consulted with an experienced qualitative researcher (N.J.) in designing these methods. Each transcript was independently reviewed and coded by 2 or 3 members of the team with a focus on the transcript content related to the personal and interpersonal impact of mindfulness practices as residents engage in clinical care. V.M. then facilitated open discussion with each of the 2 groups to identify common emergent themes. V.M. compiled the emergent themes from the 2 groups and then shared these themes with all members of the team. There was agreement across all team members that the cumulative themes were congruent with their analyses. Emergent themes from the completed interviews were similar across specialties.
This study was assigned exempt status by the University of Wisconsin Institutional Review Board because it was designated as a program evaluation.
Results
Between August 2017 and April 2019, 72 residents from 4 residency programs were invited to participate in the STREaM mindfulness training program. Session attendance for each cohort is outlined in Table 1. Thirty-six of 72 residents (50%) who participated in the training volunteered and completed interviews.
Six residents (3 family medicine, 1 anesthesiology, 1 pediatrics, 1 ophthalmology) responded during their interview that by the conclusion of the course they had not yet perceived an impact of this mindfulness training on how they practiced medicine. All residents acknowledged that mindfulness can be a useful tool in clinical practice. Through an inductive qualitative process, we identified 4 major themes related to how residents noticed mindfulness training showing up in their clinical practice: brief moments, self-awareness, relational presence, and perspective-taking.
Brief Moments
Residents across all 4 departments described ways in which mindfulness training inspired brief moments of intentional awareness in the clinical setting. The residents shared they tended to integrate their mindfulness training into certain parts of their workday and found a few practices to be particularly supportive.
Residents noted that they would practice right before going into a patient room or a surgery as well as in between seeing patients, particularly when there are heightened levels of stress present (Table 2). Brief moments of pause help when “the pace is getting too fast or just getting overwhelm[ing].” (family medicine [FM]2-9) In addition, brief moments using mindfulness training appeared to support transitioning to or away from patients whom residents identified as challenging: “When I have [...] an emotionally challenging or [...] emotionally heavy patient encounter [...] I have used some of the [...] grounding practices that they taught us to try and [...] pause.” (FM108) Another resident identified brief moments of mindfulness practice to be supportive with the task of note writing: “I've definitely used it before I go into a patient room or when I'm sitting at a computer and feeling like oh gosh [and] thinking about [...] the pile of notes I have to write.” (FM111)
Residents found walking mindfulness practices and breath awareness practices to be particularly helpful in hospital and clinic settings. One resident described how they practiced mindful walking in clinic: “The way that [mindfulness training has] shown up [for me is] walking mindfully between patient rooms [...] It's a very small piece of time, but kind of helps me feel a little grounded.” (FM102) Pausing to take a few breaths was also a common and supportive way of practicing mindfulness in brief moments (Table 2). “I do think it keeps me calmer throughout the day, especially on days where you know you have 5 admissions in 1 hour and things are crazy [...] I just have to take a couple of breaths, how do you feel, and then move along. I do, I do think I am a better physician for that.” (pediatrics [Peds]36)
Self-Awareness
After the course, residents described a greater sense of self-awareness in their clinical practices. This included being aware of sensations in the body, thoughts, and emotions, which is a core practice in mindfulness training (Table 2).
One resident noted how they experienced great awareness of body sensations: “I've tried to start noticing [...] when I am at work being like, “My heart is starting to race. I think I am starting to get agitated.” And just sitting there and coming back to the breath and rooting myself like in the chair or my feet on the floor has really helped me to not let stressful situations upset [me] as much as they used to.” (anesthesiology [A]22)
A greater identification of thought patterns was also noted after the course. One resident shared how noticing thought patterns supported patient care in the moment. “I have the patients before me, or a patient's listing off like 7 concerns and I'm feeling like we're never going to get through these. I use [mindfulness training] to [...] take a moment to reset [...] Don't worry about if you're not able to get through all of these patient's concerns. Just more like doing your best in this moment with what you are able to tackle.” (FM111)
In addition, new awareness and acceptance of residents' own emotions were noted during clinical work (Table 2): “It's really kind of a self-analysis of your emotions and [...] taking a logical look at your thought process to try and alleviate some of your stress or negative emotions that you may be going through at that time and to just try to find the center again rather than being at extreme [ranges of emotions].” (FM2-13) One resident shared how awareness of emotion supported them in identifying their own needs: “I find that doing mindfulness has let me, or has made me more aware of my feelings and made me not be too ashamed to say this is how I feel today or I need help with this.” (Peds36)
Relational Presence
Residents consistently identified mindfulness as a practice that supported their patient relationships. Specifically, residents noted present mindedness as an aid to navigating complex thought processes during clinical encounters (Table 2). “My main takeaway [from the mindfulness training] is [...] trying to be present in the moment especially with our patients and not trying to think like 20 steps ahead and just kind of appreciating where we are at the time that we are in.” (FM2-1) Another resident noted that “[Mindfulness] makes me focus more on what I'm doing with my patients instead of scatterbrained thinking about, oh I have to go do this consult or do this [‘other thing']. It sort of helps me settle in to doing what I am doing right now and focus on what I'm doing.” (Ophtho1)
In addition, this enhanced relational presence allowed residents to work through challenging encounters (Table 2), seeing patients as individuals rather than a list of problems. “I think [mindfulness training] made it easier to look at each patient [...] like [an] individual.” (FM2-5) Mindful presence during patient encounters led to a greater capacity to partner with patients and align resident and patient goals of care: “[Mindfulness training helped with] tackling those more complex patients and not getting so bogged down in the facts so much and kind of making sure we're on the same page and not coming with too many expectations of what I want to get done.” (FM2-2)
Perspective-Taking
Mindfulness helped resident physicians maintain a healthy perspective in the midst of “being within a tornado every single day.” (ophthalmology [Ophtho]5) Residents described their experience of perspective-taking through mindfulness training as taking a “step back” (Ophtho 4), a “reset” (FM108, FM111), and “bringing it down a notch.” (FM110)
This perspective-taking skill, or awareness of the larger context of their clinical work, seemed to serve residents in what might otherwise be difficult or exhausting days in residency (Table 2). “Just being a little more aware and more present throughout the day, not getting bogged down in the details and the difficulties of the situation, [...] you kind of forget big picture that this will end.” (FM2-2)
Mindfulness training allowed them to connect to a greater sense of meaning in their clinical work during residency and to recognize that they are not alone (Table 2). “[Mindfulness training] reset me, so I became more enthusiastic going back to work, I felt like a start button was pushed. [S]ometimes when you are in the midst of things you think everyone else has everything put together and it's only you running around like a chicken without their head, but when we do these mindfulness classes and you hear your colleagues talking about their struggles and how they're overwhelmed, it makes you think, ‘Oh, ok, it's not just me.'” (Peds36)
Discussion
This qualitative assessment revealed that a 10-hour mindfulness training program was used by residents across specialties and had personal and interpersonal impacts on clinical care. Analysis of resident interviews elicited 4 ways residents identified clinical skills development through mindfulness training: the use of brief moments; enhanced self-awareness of body sensations, thoughts, and emotions; improved relational presence with patients; and a greater capacity to maintain perspective amid the challenges of residency training.
A growing number of studies in health professions education have reported how mindfulness training may enhance clinical skills. For example, evaluation of a modified MBSR training for PGY-1 surgery residents demonstrated improved working memory and manual surgery skills (as measured by laparoscopic circle cutting time) in the intervention group versus the active control group.28 In a 2020 randomized controlled trial, otolaryngology residents in France were able to perform significantly better in communication and empathy in a simulated bad news consultation immediately after completing a 5-minute prerecorded mindfulness session.36 While these studies measured specific clinical skill development, they did not necessarily access the full spectrum of impact that mindfulness training had on participating resident physicians.
Our study is the first qualitative examination within both medical and procedural ACGME-accredited residency programs of resident physicians' perspectives on the impact of mindfulness training related to their clinical practices. Two prior European studies have demonstrated similar results of resident-identified improvements in clinical skills. A 2018 qualitative assessment of an MBSR training for 19 multispecialty resident physicians in the Netherlands shared themes, including residents' increased self-reflection at work while also improving work-life balance and communication with colleagues.37 In addition, a 2021 randomized controlled trial of German multispecialty resident physicians noted increased self-awareness, equanimity, and being more present with their patients.38
This qualitative approach to assess resident physicians' perspectives has the potential to inform a humanistic learner-centered educational philosophy. For example, while there are data that suggest mindfulness training may improve burnout scores,21,24,25 this approach to assessing mindfulness efficacy can be short-sighted and lead to the misconception that mindfulness training is an individual “fix” for health care crises like physician burnout that, in fact, are more appropriately and effectively improved through organizational strategies.39 By developing mindfulness training curricula based on resident physicians' self-identified clinical skills improvements, such training may have the potential to better serve residents and their future careers.
Based on this and previous studies' evaluations, there are many future areas for exploration into mindfulness training during residency. First, what is the ideal amount of time that a residency program might dedicate to resident mindfulness training? As seen in previous studies, the range of effective training may be from 5 minutes to a full MBSR class of more than 20 hours. Our work used 10 hours as a guide. It would be helpful to explore the “dose” that may inform future conversations about integrating mindfulness training into ACGME requirements. Second, what practices are most beneficial to residents? Residents in this qualitative assessment identified walking meditation and breath awareness practices as some of the most frequently applied learnings from the STREaM course. In addition, centering practices that include self-awareness, relational presence, and perspective-taking may be particularly supportive for residents' clinical skills development. A systematic evaluation of similar mindfulness training programs may be useful to focus future development of resident-specific mindfulness education. Third, long-term evaluation of clinical skills may be useful to ascertain the mindfulness practices that persist and support physicians into post-residency clinical work. Finally, assessment of mindfulness training on other aspects of patient care including treatment outcomes and patient safety, as outlined by the theoretical framework of Braun et al,33 would likely strengthen this field of study.
There are several limitations to our work. First, this evaluation is subject to participation bias, given that neither attendance nor post-training interviews were mandatory. We mitigated this limitation by hosting the sessions during protected educational time. Second, it is unclear if this specific mindfulness curriculum would be reproducible in other academic health centers as the primary author (V.M.) was involved in developing and facilitating both the pilot program and the series of trainings evaluated in this study. We invited 2 other faculty into the facilitation and curricular revisions of this course so this limitation may have been minimized. Finally, our qualitative coding method is not widely accepted; however, we developed this strategy in partnership with an experienced qualitative researcher (N.J.), and the primary author (V.M.) shared back the emergent themes with all coders to limit differences across groups and incorporate all data into common themes.
Conclusions
This study sought to understand residents' perspectives of the clinical impact of a 10-hour mindfulness training across multiple specialties. Residents found mindfulness to have personal and interpersonal impacts on clinical care, specifically in brief moments throughout their clinical work, while enhancing their self-awareness, relational presence with patients, and capacity for perspective-taking.
The authors would like to thank Maureen Goss, who facilitated all resident interviews, as well as Kevin Hanauer who transcribed them for review; the additional qualitative reviewers and coders in this process, Bruce Barrett, MD, Chris Smith, LMT, and Chris Vandivort, MD; Mindy Smith, MD, for her mentorship in the editing of this manuscript; Nora Jacobson, PhD, for assisting with designing the qualitative evaluation process; Heather Sorensen, UW Health Mindfulness teacher, who co-facilitated one of the STREaM courses; UW Health Mindfulness Program and Teachers, for their guidance, support and teaching that laid the foundation for this work; and University of Wisconsin-Madison Graduate Medication Education programs, faculty, and residents who participated in this work: Department of Family Medicine and Community Health, Department of Pediatrics, Department of Anesthesiology, and Department of Ophthalmology.
References
Funding: The authors report no external funding source for this study.
Conflict of interest: The authors declare they have no competing interests.
This work was previously presented at the virtual Academic Consortium for Integrative Medicine and Health Symposium, April 11-13, 2021.
Author notes
Editor's Note: The online version of this article contains the full course details, facilitator guide, interview questions, bracketing questions, and reviewer responses to a select question.