Nobody can question the fact that the world has a mental health problem. Nowhere is this more pronounced than in the medical health profession. American Medical Association statistics show that in 2021, physician burnout rates were 63 percent, which was almost double the rates in 2020. The CDC reports that 1 out of every five adults suffer from a mental health disease. If medications and psychotherapy are standard treatments, we should be asking if there are other first-line options to treat and/or potentially prevent mental health problems such as anxiety and depression. Mindfulness-based interventions have no negative side effects and can be used as monotherapy or as an adjunct to other treatments.
Even medical students can be at risk of stress and anxiety, and a randomized controlled trial using an app-based program improved both perceived stress and self-compassion. Unfortunately, the issue of mental health problems can worsen in medical school. One study found that 50 percent of students reported burnout symptoms, and 10 percent of students reported suicidal ideations. Other studies have shown reductions in both burnout and anxiety in orthopedic residents who used a mindfulness-based phone app for two months.
Burnout can even have negative consequences on the delivery of health care, as studies have shown that physicians suffering from burnout are more likely to make medical errors. A survey study of American surgeons found that almost 9 percent reported a medical error that could be attributed to symptoms of burnout and depression. What was even more concerning was that in a sample of American doctors, 1 out of 16 (6.3%) reported suicidal ideations, which is double the general U.S. population.
Mindfulness is a common buzzword these days, and many interchange the term with meditation. Mindfulness is an informal practice that we can use in everyday life. We can be mindful while eating, walking, or simply brushing our teeth. Once you try to be mindful and concentrate on one of those simple tasks, most people quickly discover how easily our minds and our awareness wander.
Meditation, on the other hand, is a formal practice that is thousands of years old and can be completely secular. Although one can meditate on loving-kindness or perform a contemplation or visualization practice, most commonly, people meditate on and become familiar with the present moment and use the breath as an anchor.
I began meditating almost ten years ago. For a while, my practice was an on-again, off-again practice based on time constraints due to work and raising a family. Over the past few years, my meditation practice has been an important part of my daily routine every morning. When I began a strict daily practice, those who knew me asked if I was doing something different. They commented that I seemed more relaxed and happier.
With regular meditation practice, I found that I was less reactive in everyday life, both at the office and at home. I was able to be more compassionate to others, especially my patients. I found that when difficult situations arose, I could recognize my anger or frustration without judgment, take a few breaths to calm myself down and deal with the task at hand.
A mindfulness meditation practice can help patients, too. One study demonstrated that a mindfulness-based program was non-inferior to escitalopram. Even chronic pain patients have been shown to receive benefits from mindfulness meditation programs. Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) have been shown to help those suffering from anxiety. Since patients with major depression are at risk of relapse, even with modern medication, MBCT has even been shown to decrease the chance of a relapse in patients who suffer from clinical depression. Researchers have demonstrated positive changes in both the brain as well as the immune system in patients who have pursued meditation. A mindfulness meditation practice can benefit us in many important ways.
Meditation is not a panacea. A mindfulness meditation practice did not make me immune to the stress of all of these factors, and I was burned out and suffering from moral injury. Last year, I suffered from an extreme form of burnout and was diagnosed with a major depressive episode. It was so severe that I even contemplated taking my own life. I had to take a leave of absence from work, and I sought professional help. My meditation practice helped. It kept me grounded. It was an adjunct to psychotherapy and medication. By practicing mindful, non-judgemental awareness, I was able to see my emotions and feelings for what they were, moment to moment. My meditation practice helped me begin to heal, and it still helps me survive day by day.
Thankfully, for those without a meditation background, starting a mindfulness meditation practice is quite simple and consists of three basic steps. First we take our seat, second we turn our attention to our breath, third when the mind wanders (because it will) we simply notice it, label the thought as thinking and return our attention back to the breath. We should come to the practice with non-judgemental awareness and with gentleness and patience. Each time we recognize a thought, preferably before it becomes a story, we gently redirect our attention back to the breath and consider it one mental pushup. You may perform hundreds of these mental push-ups during a twenty-minute session. Each time your mind wanders, and with awareness, you bring it back, your mind becomes stronger.
Taking your seat
To begin, you can take your seat in a chair with your feet flat on the floor. Alternatively, you may sit on the floor. If you sit on the floor, place a cushion underneath your buttocks so your hips are above your knees. In each posture, you want your spine to be loosely straight in an upright and dignified posture. By being upright but not uptight, you maintain a state of awareness and wakefulness.
Place your attention on your breath.
Once you notice your body becoming still, you place your attention on your breath wherever you notice it most strongly. This may be at your nostrils or your upper lip as the air moves back and forth. You may notice it more as the rise and fall of your chest or abdomen. It does not matter which location you choose, but pick one and stick with it. You may notice quick, shallow breaths or longer, deep, and slow breaths. The goal is not to manipulate the breath but simply to be aware of it. If you find it hard to keep your attention on the breath, you can try counting breaths starting at one and counting up to ten. If you get to ten or lose focus, simply begin again at one without judgment.
Label thoughts as thinking.
While you are doing this, thoughts will arise. When they do, simply notice them, label them as thinking, and return your attention back to your breath. You may also notice other sensations like sounds or emotions, for simplicity label them all as thinking and return the attention gently back to the breath. Occasionally, a thought becomes a story and carries you away. Simply catch yourself, label it, and gently return your attention back to the breath.
Make your practice a habit.
To get better at anything, one must practice. To play a sport or instrument takes time, effort, and practice. You probably have many habits you practice already – brushing your teeth, having your morning coffee, maybe a drink at the end of a long day – each one becomes part of your daily routine over time.
A mindfulness meditation practice can also become part of your daily routine. Consider it mental hygiene. I prefer to wake up twenty minutes earlier and spend that time on the meditation cushion before my day starts; others may find it easier to practice at the end of the day.
Expect good days where your concentration seems quite good and other days where sitting is a struggle. You may find your mind just wanders constantly, or you may feel agitated or uncomfortable. That is all part of the practice – accepting it for what it is without judgment or bias. What you may start to find is that you are less reactive, less anxious, and less stressed once you have regular practice.
Jon Kabat-Zinn has shown for decades that a mindfulness-based program can benefit health care workers and patients. You may have patients with a new mental health diagnosis that require a referral to a mental health specialist or the initiation of medication. Recommending that your patient consider starting a mindfulness meditation practice can be an effective first line treatment if you feel they would benefit. I have had anxious patients benefit by using meditation both before and after their surgery. There are many online apps such as Calm, Headspace, Healthy Minds, and Insight Timer that you and your patients can use, as well as classes and teachers that you can find both online and in person.
The best way to get going is to start. Every journey begins with the first step, which in this case is taking your seat and placing your attention on the breath, and when thoughts arise, simply label them as thinking and return your attention to the breath.
Adam Rosen is an orthopedic surgeon.
