Enhanced Stress Resilience Training for Residents
Condition: Stress; Mindfulness; Cognitive Change
Study type: Interventional

Summary: 
      Burnout and overwhelming stress are growing issues in medicine and are associated with mental
      illness, performance deficits and diminished patient care. Among surgical trainees, high
      dispositional mindfulness decreases these risks by 75% or more, and formal mindfulness
      training has been shown feasible and acceptable. In other high-stress populations formal
      mindfulness training has improved well-being, stress, cognition and performance, yet the
      ability of such training to mitigate stress and burnout across medical specialties, or to
      affect improvements in the cognition and performance of physicians, remains unknown. To
      address these gaps and thereby promote the wider adoption of contemplative practices within
      medical training, investigators have developed Enhanced Stress Resilience Training, a
      modified form of MBSR - streamlined, tailored and contextualized for physicians and trainees.
      Investigators propose to test Enhanced Stress Resilience Training (ESRT), versus active
      control and residency-as-usual, in surgical and non-surgical residents evaluated for
      well-being, cognition and performance changes at baseline, post-intervention and six-month
      follow-up.
    

Detailed description: 
      Experiencing joy in the practice of medicine is by no means guaranteed. For many physicians,
      the unique bond with patients, the deep satisfaction of saving a life, and a profound sense
      of calling make the sacrifice and heartache worthwhile. In contrast, the growing prevalence
      of burnout, and mental distress is being linked to diminished physician performance, patient
      outcomes, and hospital economics. This suggests that demands are outstripping resources,
      thereby threatening the physician-patient bond and the societal pillar this represents.

      Overwhelming stress without adequate coping skills has been posited to promote burnout and
      distress, and may promote performance deficits (from surgical errors to poor professionalism)
      by impairing cognition and self-regulation. In other high-stress/high-performance groups
      formal mindfulness training has been shown to enhance stress resilience, subjective
      well-being and performance. Nevertheless, quality research involving physicians, the effects
      of chronic stress on performance and the impact of mindfulness training in this context
      remains scarce, contributing to the slow adoption of mindfulness training into medical
      practice and residency.

      To address these gaps, we first laid the groundwork: we conducted a national survey which
      showed high dispositional mindfulness in surgery residents reduced the risk of burnout and
      distress by 75% or more. We conducted a RCT of MBSR in surgery interns, demonstrating
      feasibility and acceptability of formal mindfulness training. Finally, we have developed an
      MBSR-based, streamlined curriculum tailored for physicians and trainees, Enhanced Stress
      Resilience Training (ESRT), which has been beta-tested in surgery faculty and mixed-level
      residents and refined in terms of logistics, dose and delivery. We have since disseminated
      our promising results, thereby allowing us access to a larger study population for our
      proposed RCT of ESRT in mixed-specialty interns as a means to improve well-being, cognition
      and performance.

      While this study will likely not reach statistical power, it will absolutely allow for
      broader vetting of the curriculum, our current data acquisition and management methods, and
      the appropriateness of our outcome measures, paving the way for a high-quality, fully-powered
      MCT in the near future.

      The significance of studying mindfulness mental training in medical and surgical trainees is
      two-fold. One, as a process-centered skill with demonstrated effects on psychological
      well-being, perceived stress, cognitive performance and physiologic health mindfulness
      presents a potential gateway mechanism for providing individuals with a 'universal tool' for
      challenges across all stages of medical training and practice. This includes burnout and
      errors which are looming issues, largely immutable for the last decade. Two, if feasibility
      and efficacy among medical and surgical trainees can be shown, the social clout of impacting
      such a high stress and high performance field is uniquely powerful and could further the
      dissemination of evidence-based mindfulness interventions to a remarkable degree. Finally,
      the resultant tendency for enhanced self-awareness and equipoise has been contagious in other
      settings, providing fuel for a greater culture change in medicine that is much-needed and
      holds great promise for patients and providers.

      The innovation of this work is in bringing a mind-body intervention to bear not only on
      well-being but also on the fundamental cognitive processes believed to sub-serve performance,
      such as the impact of attention and working memory capacity on medical decision-making, and
      the impact of emotional regulation and self-awareness on professionalism and team work. The
      potential to improve both the operative and clinical environments as well as medical errors
      is unprecedented. Finally, a vetted, manualized curriculum specifically crafted for
      physicians could accelerate dissemination nationally.
    

Intervention name(s): Enhanced Stress Resilience Training (ESRT); Active Control
Intervention type(s): Behavioral; Behavioral
Intervention description(s): ESRT involves six weekly 90-minute group classes and one 2 - 4 hour retreat. Classes focus on developing mindfulness skills (i.e. sustained attention, open monitoring, emotional regulation, meta-cognition) in the context of skills and concepts for managing stress, particularly in practicing medicine. Homework consists of 20 minutes per day of mindfulness exercises following guided meditation CDs or videos of movement-based practice, and practice will be reported periodically by text. A 3-hour outdoor retreat occurs at week six. The central exercises of ESRT are the body scan, sitting meditation, chi gong and yoga. For both arms, the weekly teaching sessions occur on a workday morning during protected time at Parnassus, Mission Bay or Zuckerberg San Francisco General Hospital campus.; Control group participants will meet for 6 weeks, 90 minutes each week, for classes focuses on stress management through rest and exercise, with equivalent protected time and small group bonding but without the use of contemplative practices. Topics will include the history of surgery, patient perspective, the physician personality, technical mastery, fallibility and limits, balancing compassion and detachment and knowing when not to operate. For daily practice, control participants will be asked to devote 20 min per day to stress management through rest and exercise again reported daily by text.
Other intervention name(s): Modified MBSR
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized, partially-blinded.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention
Keywords: Residents; Stress; Well-being