Mindful Practice Curriculum

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					                                                 Mindful Practice Curriculum for Psychiatry Residents: Experience as
                                                                  Part of a University Wide Program
                                             Tana A. Grady-Weliky MD, Sue K. DiGiovanni, MD, Scott McDonald, MD, Jennifer Richman, MD,
                                               Anola Tanga, MD, David Garrison, MD, Christopher Mooney, MS and Ronald M. Epstein, MD
                                                                        University of Rochester Medical Center
                                                                               Department of Psychiatry

                          Abstract                                               Curriculum Goals and Objectives                                                              Narrative Exercise Instructions
Mindful practice refers to our ability to be aware, in the moment, on
purpose, with the goal of providing better care to patients and to take                                 Goals of Mindful Practice                                                                                For the listener:
better care of ourselves. The University of Rochester School of Medicine                                                                                                                                              •Be attentive
and Dentistry developed a program designed to give medical students,                                                      •Clinical reasoning                   For the storyteller, address:
                                                                                                                          •Patient safety
                                                                                                                                                                                                                      •Listen without interrupting or
residents and practicing physicians‟ tools that will assist them in                               Mindful Practice                                              •What happened?
becoming more mindful during daily clinical practice. The explicit aim of                                                 •Compassion                                                                                 responding too quickly
                                                                                                 •Attentive observation                                         •What helpful qualities did you bring
the curriculum is to help participants develop self-awareness and self-care                      •Critical curiosity      •Technical skills                                                                           •Ask questions to help your
skills so that they can be attentive and present in clinical settings. Self-                                              •Healing relationships
                                                                                                                                                                to that moment?
                                                                                                 •Informed flexibility                                                                                                partner elaborate, clarify and
awareness is an essential component of communication, technical skill,                           •Presence                •Teamwork                             •Who else was involved, and how did
professionalism, teamwork and life-long learning. All of these attributes                                                                                                                                             provide details
                                                                                                                          •Physician well-being                 they contribute?
are included among the ACGME core competencies and are critical to                                                                                                                                                    •Don‟t talk about your own ideas
training all residents, and perhaps, psychiatrists, in particular. Because of
                                                                                                                                                                •What aspects of the context made a
                                                                                                                                                                                                                      or experiences
the importance of the development of these attributes in resident                                                                                               difference?
                                                                                     Mindful Practice curriculum goals are to foster skills of attentive                                                              •Use reflective questions
physicians, the general psychiatry program elected to have its residents                                                                                        •What lessons from this story are
participate in the university-wide program. General psychiatry residents        observation, critical curiosity, informed flexibility and presence in                                                                 •Pay attention to what is attracting
                                                                                                                                                                useful to you?
from across the four years are required to attend the Mindful Practice
                                                                                trainees at multiple levels.                                                                                                          your attention, and what you might
curriculum sessions, which include the following sessions: 1) Noticing                                                                                                                                                not (or rather not) be hearing
and Attention; 2) Professionalism; 3) How Doctor‟s Think; 4) Physician               Specific curricular objectives include:
Self Care and Burnout; and 5) Dealing with Medical Errors. Several              •To further professional development                                                                                                  •Offer empathy if you feel it
educational methods are used throughout the curriculum including brief
                                                                                        Improve recognition of error-prone situations, reduce medical
meditation exercises, written narratives and “appreciative inquiry”
interviews. This poster will describe further details of the curriculum and           errors and improve reporting;                                                        2007-2009 Curriculum Modules
include qualitative and quantitative data about the course.                             Foster caring attitudes toward patients;
                                                                                        Promote professionalism, and prevent, recognize and deal with
                                                                                      lapses in professionalism;                                                                     2007-2008                             2008-2009
                                                                                        Promote physician health and well-being.
    Educational Objectives                                                      •To enhance the institutional culture to facilitate the aforementioned
                                                                                                                                                                           oNoticing and Attention
                                                                                                                                                                                                                      oTeams and Partnerships
                                                                                training goals through                                                                     oHow Doctor‟s Think                        oBalance
                                                                                        More open discussion of medical errors;                                            oPhysician Self-Care and Burnout*
  1.     Define mindful practice and its role in the                                                                                                                                                                  oManaging Conflict
                                                                                        Focus on teamwork and leadership;                                                  oDealing with Medical Errors*
         clinical care of patients.                                                     Modeling of effective patient care;                                                * Well-received by psychiatry residents
  2.     List at least two components of mindfulness.                                   Working on means to enhance physician health and well-being.
  3.     Identify at least two new educational                                  •To help residency programs meet ACGME competencies
         methods for teaching mindful practice to                                       Communication - through more attentive listening to patients;
         psychiatric residents.                                                         Professionalism - through examining biases and threats to          Curriculum Assessment & Resident Feedback
                  Introduction                                                          Systems-based practice - by examining and intervening to reduce
                                                                                   individual contributions to medical errors;
                                                                                                                                                                  In the 2007-2008 academic year residents completed several surveys, including the
                                                                                                                                                           Maslasch Burnout Inventory (MBI), prior to and following participation in this curriculum. No
                                                                                        Practice-based learning and Improvement - through greater          statistical differences were found in the group (n=16) for any of the pre- and post- survey
                                                                                   openness and flexibility and a decreased tendency to premature          instruments. This is not too surprising given the small number of resident participants.
      Patient-centered and biopsychosocial models of                               closure.                                                                Moreover, statistical differences in the survey instruments may not be found after a relatively
care are essential elements of medical education. The                                                                                                      brief intervention.
important roles of relationship-centered care and a                                         Reflective Questions: Habits of Self-Questioning                      Unfortunately, a general anonymous course evaluation was not obtained for the 2007-2008
humanistic approach to care were highlighted in the                                                                                                        year. However, individual and group verbal feedback described a sense of redundancy of the
Health Professions Education IOM report (2001) and                               Attentive Observation                                                    narrative exercises with what is accomplished in psychotherapy supervision. They also noted
the AAMC Ad Hoc Committee Report on Medical                                          oIf there were data that you ignored, what might they be?             that psychiatry residents are frequently talking about positive and negative interactions with
Education (2004). Recently, there has been more focus                                oWhat did you notice? What were you unable to see?                    patients, which made some of the sessions less beneficial. Only two of five sessions were highly
on the role of the „narrative‟ in medical and residency                                                                                                    regarded by the residents – Physician Self-Care and Burnout and Dealing with Medical Errors.
education. The concept of narrative medicine includes                            Critical Curiosity                                                       Based on this feedback we selected four new modules for the 2008-2009 academic year. The
the essential nature of closely examining each patient‟s                            oWhat are you assuming that might not be true?                         new modules are more practical in nature and may be better received by the residents.
story in order to provide better medical care. Connelly                             oWhat was surprising or unexpected?
addresses how the concepts of self-reflection and
mindfulness are critical factors in being able to fully hear                     Beginner‟s Mind
                                                                                                                                                                                Discussion                                        1.
                                                                                                                                                                                                                                       Connelly JE: Narrative Possibilities: Using
the patient‟s story and to help relieve their suffering.1                           oWhat would a trusted peer say about how you managed or feel
                                                                                                                                                                                                                                       Mindfulness in Clinical Practice. Perspectives
                                                                                                                                                                                                                                       in Biology and Medicine. 48(1): 84-94, 2005.
Training students and residents to become more self-                                                                                                             Self-reflection, narrative medicine and mindful practice are     2.   Dobie S: Reflections on a Well-Traveled
                                                                                    about this situation?                                                                                                                              Path: Self-Awareness, Mindful Practice and
aware and to engage in mindful practice may not only                                                                                                       elements needed for successful practice in today‟s health care
                                                                                    oCan you see the same situation or patient with new eyes?                                                                                          Relationship Centered Care as Foundations

improve patient care, but also reduce career                                                                                                               environment. Psychiatric, and other medial educators need to                for Medical Education. Academic Medicine
                                                                                                                                                                                                                                       82: 422-427, 2007.
dissatisfaction/burnout and facilitate wellness.2 In fact,                                                                                                 understand the role that training in this area has not only for        3.   Hassed C, deLisle S, Sullivan G and Ciaran
                                                                                 Presence                                                                                                                                             P: Enhancing the health of medical students:
Hassed and colleagues found improved physical and                                                                                                          enhanced patient care, but also for the well-being of our                   outcomes of an integrated mindfulness and
                                                                                    oWhat do you notice about yourself when you are at your best?                                                                                      lifestyle program. Adv in Health Sci Educ.
psychological well-being among medical students who                                                                                                        residents. Moreover, training also involves critical components             DOI 10.1007/s10459-008-9125-3, 2008.
                                                                                    oWhat moved you most about this situation?
participated in a mindfulness-based stress reduction                                                                                                       of several ACGME Core Competencies. Although our data did
program.3 The Mindful Practice Curriculum at the                                                         Educational Techniques                            not reveal a significant pre-/post- course difference in survey
University of Rochester was initiated in 2007 with the                           Appreciative Inquiry – focus attention on existing capacities and        instruments, there are a couple of limitations that may explain
primary goal of fostering skills of attentive observation,                       prior successes in relationship building and problem solving.             this finding. First, we have a small residency program, which
critical curiosity, informed flexibility, and presence in                        Personal Narratives – sharing of “real-life” or clinical stories based   resulted in a small „n‟. Second, significant change may not be
trainees at all levels.                                                          on the topic being addressed in the curriculum                            found after brief exposure to a new concept. Further
                                                                                 Reflective Questions – help cultivate curiosity and new ways of          investigation is needed to determine the effectiveness of this
                                                                                 seeing the world and may enhance one‟s ability to listen and observe      curriculum for psychiatric residents.

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