Physician engagement: mindfulness as part of the pandemic solution

With COVID stress taking its toll on physicians, a Yale psychiatrist gives advice on why – and how – to stay mindful and motivated

By Frank John Ninivaggi, MD - May 21, 2020

The current medical crisis is an unexpected global challenge. We have been forcibly evicted from comfortable routines. A novel virus, SARS-CoV-2, confounds established approaches. Confusion, anxiety and uncertainty abound. More than an intensive care phenomenon, this disaster is a crisis — public health and humanitarian.

Pandemic solutions require the entire population to engage. Clinicians and physicians must assume a broad leadership that includes self-care with the care of others. This perspective embraces COVID-19 patients without forgetting those having other medical needs. Wellness thus scales upward and becomes inclusive. Physician wellness is rooted in personal accountability (e.g., autonomy, humanely practicing in competent ways, and social-emotional relatedness to the healthcare organization and its demands) and organizational alignment.

A profound lack of alignment between caregivers’ values and the up-to-now reconfigured healthcare system needs radical reassessment and realignment. Organizational mindfulness with real-time change demands attention. A scrupulous examination can never underestimate the role of the electronic health record (EHR) and a physician’s sense of “moral injury.” The healthcare crisis that prevails now is an impetus for rapid learning piloting dynamic, permanent change.

COVID-19 is a disease calling for renewed physician engagement. The engaged physician has a dedicated commitment to studying, enhancing expertise, and applying skills toward safe, high-quality patient care. These assets go beyond assigned responsibilities. They pivot on intentional self-care. These are issues I examine in my book Learned Mindfulness: Physician Engagement and MD Wellness (Elsevier, 2019).

In Chapter 6, I detail the components of engagement and how mindfulness can be used as a practical tool.

The burnout syndrome and how mindfulness can help

For clinicians, the burnout syndrome has been a developing phenomenon marked by demoralization and ultimately self-sabotaging trajectories. Exhaustion, depersonalization, and feelings of professional inadequacy make up its hallmarks. What had been prevalent as indolent distress now is exacerbated by real-life, overwhelming challenges now and coming. Depression and PTSD from COVID-19, distinct from burnout, can superimpose themselves and further impair one’s functioning.

The burnout syndrome shows itself with exhaustion as physical fatigue and emotional depletion. A lack of enthusiasm makes a recovery difficult. Depersonalization takes over when overwhelming stress leads to physical and emotional withdrawal. Cynicism about the sincerity of others and one’s competence organize into numbing attitudes. Feeling this avalanching depletion and inability to recover numbs reason and clear thinking. Doctors now seriously doubt their skill, competence, and effectiveness. Mindfulness counters burnout.

Mindfulness is a concept, practice and mindset. To some, it is merely relaxed meditation; to others, it is a focused concentration. As the ancient Greek philosopher Heraclitus said of opposite tensions: the truth is simple-difficult. Putting the enormity and complexity of mindfulness in a few words might read: present moment awareness, even amid ambiguous uncertainty.

Subjectively, one’s implicit voice echoes: “Here I am,” sparking immersion in the moment. This ability has a hub in nonverbal working memory, which centers on self-directed sensing, mental imagery and a flowing awareness of time.

Engaging in effective mindfulness is pausing, breathing slowly, paying attention in the present moment, on purpose and non-judgmentally. Entering the mindfulness journey requires a phased approach. The best entry is to begin at whatever level is understandable and comfortable. Gradually layering your “practice” to integrate simpler steps into more complex configurations ensures sustainability. Amid this, maintaining an underlying curiosity amplifies one’s receptivity to learning. Curiosity characterizes the prepared mind, ready to take chances when opportunities appear. Preparation underlies the robust resilience of those exposed to stress and trauma. Thus, the current dilemma of physician burnout is countered by the resilient mindset that mindfulness imparts.

Can we “update” the brain?

Physician engagement includes wholehearted commitment. With this comes a restoration in hope. Hope implies that different outcomes, while unrealized, are genuinely possible. From a neurological perspective, the “old brain” and limbic system dedicated to brute survival is now enhanced by the “new brain” of frontal lobes and critical thinking. This relevant advance means that old patterns need updating with new values and new reward systems with compelling significance. Implicit here is that curiosity and learning, not anger, blame, polarization and attack, can lead to judicious thinking.

The unexpected is met with an explorative curiosity, not frustration and aversion. Curiosity counters fear when knowledge intervenes to fill in the gaps of unknowing uncertainties. Curiosity leads to rapid learning when one’s plan, actions, and outcomes are continuously analyzed and improved. The future healthcare delivery system calls for better preparation for future pandemics (e.g., by federal, state, hospital and individual clinicians), more telehealth and virtual care, and payment reform. Value-based healthcare is a key theme.

“Practicing pause” is a keynote in Learned Mindfulness. Practicing pause enhances the periodic enactment of patience. It is paying attention mindfully at each moment. Both patience and pause are slowing down from a hurried pace. Quiet time thus provides the opportunity for targeted self-observation. Moments of relaxation relocate attention from isolated thinking to include bodily awareness. Retrospective reflection as emotional comprehension ensues.

Mindfulness as a mindset strengthens emotional equanimity and mindful equipoise. Emotional equanimity is mood stability that yields a quiet sense of comfort and lowered anxiety. It is calm, tranquility and a reminder that peace of mind is real. Thus, equanimity as composure platforms the mindful equipoise modulating impulsive reactivity. Breaking the harmful loop of anxiety triggering poor choice then becomes available. All this creates a mindful readiness toward mental and emotional equipoise, a clear and balanced mind.

The subjective side of well-being and wellness comprises this psychological equipoise, a dynamic balance, often of antagonistic forces. This active moderation is constructive and an orienting mindful mindedness, a key messaging platform. Equipoise is the balance between extremes, a modulated equilibrium.

Making mindfulness a lifestyle

Learned mindfulness as a lifestyle brings forth increased awareness of these upgrades and the skills needed to embrace them. For example, although faced with developing COVID-19 emergencies, the mindful practitioner realizes that life is not an emergency but a plethora of opportunities. This expansion in possibilities causes pause that reduces, albeit temporarily, frenetic over activity and exhaustion. Taking stock mindfully of precious personal resources and those around us reconfigures the depersonalization that burnout and a numbed mind promote. The uncertainties barraging self-adequacy become countered by an increasing empathy that is self-based and extends to others. Hope restoration is an appreciated outcome previously unencountered. Overwhelming threats can become complex yet manageable challenges, a catalyst for transformative advances.

How an organization can support a mindful approach to work

This discussion on mindfulness has so far focused on the individual physician. This is only one half of the total equation. The other crucial side is the organization or hospital system in which practice works. Mindful organizational alignment with physician values and well-being are detailed in Chapter 6. Physicians require greater hospital regard for their mounting needs. One of the outstanding changes in medicine has been the expansion of virtual platforms in healthcare delivery. This amplification includes telehealth, e-visits, and the optimization of artificial intelligence (AI) to complement and support effective delivery. Those in healthcare and the public domain have realized the crucial importance of unified communication among healthcare professionals, organizations and governmental leaders. This acute phase needs leadership competency more than ever. As we approach the “tail” of the crisis and look (with trepidation?) to subsequent waves, unified leadership remains paramount.

While physical distancing undoubtedly is needed, social engagement on an emotionally sensitive level is mandated. Thus, mental flexibility adapts even to paradox. The challenges of managing individual responses to COVID-19 must work in coordination with a clinical redesign and administrative leadership. Hospital workflows, for example, need a major rehaul toward safety and efficiency. “Redesign” is not optional but a mandate. A new cadence must emerge. Mindfulness as physician self-care is an augmentation that drives one’s unique platform of values, ethics, science, research, education, communication and resilience.

Present moment awareness is oxygen to the mind. You are your unique “index case” — here self-identified as waking up to mindful mindedness. Unlike COVID-19, which can be contracted passively, “mindful” living must be embraced actively.

Book excerpt: 7 steps toward mindful goal setting

Learned Mindfulness has differentiated itself gently from the past, present and future-oriented cognitive abilities that critical thinking, executive functioning, and calibrated choice afford. Mindfulness practice is a “time-out” from everyday critical thought. As mentioned in earlier chapters, mindfulness memory becomes the equipoised platform of daily living. Its intention is an orientation of mindfulness readiness toward a process of mindful living. Goals, however, are intrinsic to critical thinking and aim toward future desired outcomes. When critical thinking is needed, goals can be accessed more efficiently. Here, in goal setting, these valuable higher-order cognitive skills now come into play.

Value-based medicine highlights the return on investment from successful patient health outcomes. These positive outcomes have their roots in physician mindfulness: paying attention mindfully as a mode of clear awareness, curiosity, openness, and acceptance. Such relaxed alertness is a conscious intention: an engaging “presence of mind” at every moment. This background program works together with critical thinking, synergistically optimizing its proficiency toward value-based outcomes.

In the workforce, orienting oneself for optimal task performance includes layers of perspective-taking. Time management means viewing the big picture, then organizing a hierarchy of priorities. Determinants for these levels of importance come from several strategic inputs: externally imposed obligations already embedded in the work system, emerging challenges that are unexpected, and the prioritization one configures to these. New rewards create new behaviors. Tasks, frames of reference, and time sequences—conscious results of critical thinking—thus arise. Designing goals is a shorthand way of expressing this complex set of processes.

Within goals are the levels or steps leading to transformative learning. This delineation creates aspirational motivation for achieving an improved future. Steps toward this include:

  1. Setting concrete goals, identifying specific behaviors, and measuring emerging results.
  2. Learning the abilities needed to perform the required skills.
  3. Developing an enthusiasm for those continuing behaviors.
  4. Giving positive, encouraging feedback to oneself and one's collaborative team.
  5. Providing timely, unembarrassing help and direction when asked for or needed.
  6. Explaining why the goal and the actions to achieve them are necessary, based on performance — refining a flexible scope of “how to” behavior options.
  7. Continually providing concrete, visual cues everywhere, mainly by living example.

Source: Chapter 6, Physician Wellness: Engaging Mindfulness, Learned Mindfulness: Physican Engagement and MD Wellness (Academic Press, Elsevier, 2019)

Read Dr. Ninivaggi’s book: Learned Mindfulness

Because of the relevance of this book to the COVID-19 pandemic, we have made it freely available until the end of this crisis.

Learned Mindfulness coverLearned Mindfulness: Physician Engagement and MD Wellness (Academic Press, Elsevier, 2019) is aimed at clinical psychiatrists, psychologists, and physicians and researchers interested in mindfulness. Dr. Ninivaggi provides a comprehensive discussion of mindfulness in perspective in Chapter 1 and emotional awareness and mindfulness in Chapter 3. Chapter 6, “Physician Wellness: Engaging Mindfulness,” elaborates themes of engaged mindfulness. Chapter 2, “Modern Mindfulness,” outlines and discusses the elements of mindfulness and its multifaceted practices in contemporary culture. Chapter 4, “Learned Mindfulness,” integrates an emotional intelligence perspective. Chapter 5, “Authentic Integrity,” addresses the platforms of character strength and resilience.

Related stories and resources

Find more resources in the Mental and Behavioral Health section of Elsevier’s COVID-19 Healthcare Hub.

Doug Neill cartoon
Dr. Temple Grandin on Mark Deesing's ranch (Photo © 2020 Callen Liverance)

Written by

Frank John Ninivaggi, MD

Written by

Frank John Ninivaggi, MD

Dr. Frank John Ninivaggi, MD, is an Associate Attending Physician at Yale-New Haven Hospital, Assistant Clinical Professor of Child Psychiatry at the Yale University School of Medicine’s Child Study Center, and Psychiatric Director of the Devereux-Glenholme School in Washington, Connecticut.

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