Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial
Carter C Lebares, Ekaterina V Guvva, Maria Olaru, Leo P Sugrue, Adam M Staffaroni, Kevin L Delucchi, Joel H Kramer, Nancy L Ascher, Hobart W Harris, Carter C Lebares, Ekaterina V Guvva, Maria Olaru, Leo P Sugrue, Adam M Staffaroni, Kevin L Delucchi, Joel H Kramer, Nancy L Ascher, Hobart W Harris
Abstract
Importance: Mindfulness meditation training has been shown to be feasible in surgical trainees, but affective, cognitive, and performance benefits seen in other high-stress populations have yet to be evaluated.
Objective: To explore potential benefits to stress, cognition, and performance in postgraduate year 1 (PGY-1) surgery residents receiving modified mindfulness-based stress reduction (modMBSR).
Design, setting, and participants: This follow-up study is an analysis of the Mindful Surgeon pilot randomized clinical trial of modMBSR (n = 12) vs an active control (n = 9), evaluated at baseline (T1), postintervention (T2), and 1 year (T3), took place at an academic medical center residency training program among PGY-1 surgery residents. Data were collected between June 2016 and June 2017 and analyzed from June 2017 to December 2017.
Interventions: Weekly 2-hour modMBSR classes and 20 minutes of daily home practice during an 8-week period vs an active control (different content, same structure).
Main outcomes and measures: Preliminary evidence of efficacy was explored, primarily focusing on perceived stress and executive function and secondarily on burnout, depression, motor skill performance, and changes in blood oxygen level-dependent functional neuroimaging during an emotion regulation task. Group mean scores were calculated at T1, T2, and T3 and in linear mixed-effects multivariate analysis. Effect size for analysis of covariance is presented as partial η2 with the following cutoff points: small, less than 0.06; medium, 0.06 to 0.14; large, greater than 0.14.
Results: Postgraduate year 1 surgery residents (N = 21; 8 [38%] women) were randomized to a modMBSR arm (n = 12) or an active control arm (n = 9). Linear mixed-effects modeling revealed differences at T2 and T3 in perceived stress (mean [SD] difference at T2: modMBSR, 1.42 [5.74]; control, 3.44 [6.71]; η2 = 0.07; mean [SD] difference at T3: modMBSR, 1.00 [4.18]; control, 1.33 [4.69]; η2 = 0.09) and in mindfulness (mean [SD] difference at T2: modMBSR, 3.08 [3.63]; control, 1.56 [4.28]; η2 = 0.13; mean [SD] difference at T3: modMBSR, 2.17 [3.66]; control, -0.11 [6.19]; η2 = 0.15). Burnout at T2 (mean [SD] difference: modMBSR, 4.50 [9.08]; control, 3.44 [6.71]; η2 = 0.01) and T3 (mean [SD] difference: modMBSR, 5.50 [9.96]; control, 5.56 [9.69]; η2 = 0.01) showed similar increase in both groups. Working memory increased more at T2 in the modMBSR arm (mean [SD] difference, 0.35 [0.60]) than in the control arm (mean [SD] difference, 0.21 [0.74]; η2 = 0.02) and at T3 (modMBSR, 0.68 [0.69]; control, 0.26 [0.58]; η2 = 0.20). Cognitive control decreased more in the control arm at T2 (mean [SD] difference at T2: modMBSR, 0.15 [0.40]; control, -0.07 [0.32]; η2 = 0.13) and at T3 (mean [SD] difference: modMBSR, 0.07 [0.59]; control, -0.26 [0.53]; η2 = 0.16). Mean (SD) circle-cutting time improved more at T2 in the modMBSR arm (-24.08 [63.00] seconds) than in the control arm (-4.22 [112.94] seconds; η2 = 0.23) and at T3 in the modMBSR arm (-4.83 [77.94] seconds) than in the control arm (11.67 [145.17] seconds; η2 = 0.13). Blood oxygen level-dependent functional neuroimaging during an emotional regulation task showed unique postintervention activity in the modMBSR arm in areas associated with executive function control (dorsolateral prefrontal cortex) and self-awareness (precuneus).
Conclusions and relevance: In this pilot randomized clinical trial, modMBSR in PGY-1 surgery residents showed potential benefits to well-being and executive function, suggesting a powerful role for mindfulness-based cognitive training to support resident well-being and performance, as mandated by the Accreditation Council for Graduate Medical Education.
Trial registration: ClinicalTrials.gov identifier: NCT03141190.
Conflict of interest statement
Conflict of Interest Disclosures: Dr Staffaroni reported grants from the National Institutes of Health and grants from Larry L. Hillblom Foundation during the conduct of the study. No other disclosures were reported.
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References
- Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW, Epel ES. Burnout and stress among US surgery residents: psychological distress and resilience. J Am Coll Surg. 2018;226(1):-. doi:10.1016/j.jamcollsurg.2017.10.010
- Arora S, Sevdalis N, Aggarwal R, Sirimanna P, Darzi A, Kneebone R. Stress impairs psychomotor performance in novice laparoscopic surgeons. Surg Endosc. 2010;24(10):2588-2593. doi:10.1007/s00464-010-1013-2
- Wetzel CM, Kneebone RL, Woloshynowych M, et al. . The effects of stress on surgical performance. Am J Surg. 2006;191(1):5-10. doi:10.1016/j.amjsurg.2005.08.034
- Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246(5):705-711. doi:10.1097/SLA.0b013e31815865f8
- Dyrbye LN, Massie FS Jr, Eacker A, et al. . Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173-1180. doi:10.1001/jama.2010.1318
- Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146. doi:10.1016/j.mayocp.2016.10.004
- Panagioti M, Panagopoulou E, Bower P, et al. . Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205. doi:10.1001/jamainternmed.2016.7674
- West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X
- Bohman B, Dyrbye L, Sinsky C, et al. Physician well-being: the reciprocity of practice efficiency, culture of wellness, and personal resilience. . Accessed March 11, 2019.
- Brigham T, Barden C, Dopp AL, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. . Accessed March 11, 2019.
- Haglund ME, Nestadt PS, Cooper NS, Southwick SM, Charney DS. Psychobiological mechanisms of resilience: relevance to prevention and treatment of stress-related psychopathology. Dev Psychopathol. 2007;19(3):889-920. doi:10.1017/S0954579407000430
- Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. Science. 2012;338(6103):79-82. doi:10.1126/science.1222942
- Sousa N, Almeida OF. Disconnection and reconnection: the morphological basis of (mal)adaptation to stress. Trends Neurosci. 2012;35(12):742-751. doi:10.1016/j.tins.2012.08.006
- Johnson DC, Thom NJ, Stanley EA, et al. . Modifying resilience mechanisms in at-risk individuals: a controlled study of mindfulness training in Marines preparing for deployment. Am J Psychiatry. 2014;171(8):844-853. doi:10.1176/appi.ajp.2014.13040502
- Krasner MS, Epstein RM, Beckman H, et al. . Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293. doi:10.1001/jama.2009.1384
- Amutio A, Martínez-Taboada C, Hermosilla D, Delgado LC. Enhancing relaxation states and positive emotions in physicians through a mindfulness training program: a one-year study. Psychol Health Med. 2015;20(6):720-731. doi:10.1080/13548506.2014.986143
- Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L. Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion. 2010;10(1):54-64. doi:10.1037/a0018438
- MacLean KA, Ferrer E, Aichele SR, et al. . Intensive meditation training improves perceptual discrimination and sustained attention. Psychol Sci. 2010;21(6):829-839. doi:10.1177/0956797610371339
- Mrazek MD, Franklin MS, Phillips DT, Baird B, Schooler JW. Mindfulness training improves working memory capacity and GRE performance while reducing mind wandering. Psychol Sci. 2013;24(5):776-781. doi:10.1177/0956797612459659
- Baird B, Mrazek MD, Phillips DT, Schooler JW. Domain-specific enhancement of metacognitive ability following meditation training. J Exp Psychol Gen. 2014;143(5):1972-1979. doi:10.1037/a0036882
- Flook L, Goldberg SB, Pinger L, Bonus K, Davidson RJ. Mindfulness for teachers: a pilot study to assess effects on stress, burnout and teaching efficacy. Mind Brain Educ. 2013;7(3). doi:10.1111/mbe.12026
- McCrory P, Cobley S, Marchant P. The effect of psychological skills training on self-regulation behavior, self-efficacy, and psychological skill use in military pilot trainees. Mil Psychol. 2013;25(2):136-147. doi:10.1037/h0094955
- Le Scanff C, Taugis J. Stress management for police special forces. J Appl Sport Psychol. 2002;14(4):330-343. doi:10.1080/10413200290103590
- Guenthner SV, Hammermeister J, Burton D, Keller L. Smoke and mirrors or wave of the future? evaluating a mental skills training program for elite cross-country skiers. J Sport Behav. 2010;33(1):3-24.
- Birrer D, Röthlin P, Morgan G. Mindfulness to enhance athletic performance: theoretical considerations and possible impact mechanisms. Mindfulness. 2012;3(3):235-246. doi:10.1007/s12671-012-0109-2
- Khalsa SS, Rudrauf D, Feinstein JS, Tranel D. The pathways of interoceptive awareness. Nat Neurosci. 2009;12(12):1494-1496. doi:10.1038/nn.2411
- Craig AD. How do you feel? interoception: the sense of the physiological condition of the body. Nat Rev Neurosci. 2002;3(8):655-666. doi:10.1038/nrn894
- Hölzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U. How does mindfulness meditation work? proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Sci. 2011;6(6):537-559. doi:10.1177/1745691611419671
- Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New: York, NY: Bantam Books; 2013.
- Fernandez-Duque D, Baird JA, Posner MI. Executive attention and metacognitive regulation. Conscious Cogn. 2000;9(2, pt 1):288-307. doi:10.1006/ccog.2000.0447
- Karlamangla AS, Singer BH, McEwen BS, Rowe JW, Seeman TE. Allostatic load as a predictor of functional decline: MacArthur studies of successful aging. J Clin Epidemiol. 2002;55(7):696-710. doi:10.1016/S0895-4356(02)00399-2
- McEwen BS. In pursuit of resilience: stress, epigenetics, and brain plasticity. Ann N Y Acad Sci. 2016;1373(1):56-64. doi:10.1111/nyas.13020
- Paas F, Renkl A, Sweller J. Cognitive load theory and instructional design: recent developments. Educ Psychol. 2003;38(1):1-4. doi:10.1207/S15326985EP3801_1
- Lebares CC, Hershberger AO, Guvva EV, et al. . Feasibility of formal mindfulness-based stress-resilience training among surgery interns: a randomized clinical trial. JAMA Surg. 2018;153(10):e182734. doi:10.1001/jamasurg.2018.2734
- Onken LS, Carroll KM, Shoham V, Cuthbert BN, Riddle M. Reenvisioning clinical science: unifying the discipline to improve the public health. Clin Psychol Sci. 2014;2(1):22-34. doi:10.1177/2167702613497932
- Huey SJ Jr, Weisz JR. Ego control, Ego resiliency, and the Five-Factor Model as predictors of behavioral and emotional problems in clinic-referred children and adolescents. J Abnorm Psychol. 1997;106(3):404-415. doi:10.1037/0021-843X.106.3.404
- Moffitt TE, Arseneault L, Belsky D, et al. . A gradient of childhood self-control predicts health, wealth, and public safety. Proc Natl Acad Sci U S A. 2011;108(7):2693-2698. doi:10.1073/pnas.1010076108
- Feldman G, Hayes A, Kumar S, Greeson JG, Laurenceau JP. Mindfulness and emotion regulation: the development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). J Psychopathol Behav Assess. 2007;29(3):177-190. doi:10.1007/s10862-006-9035-8
- Duckworth AL, Quinn PD. Development and validation of the Short Grit Scale (Grit-S). J Pers Assess. 2009;91(2):166-174. doi:10.1080/00223890802634290
- Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. doi:10.2307/2136404
- McManus IC, Winder BC, Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet. 2002;359(9323):2089-2090. doi:10.1016/S0140-6736(02)08915-8
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x
- Kramer JH, Mungas D, Possin KL, et al. . NIH EXAMINER: conceptualization and development of an executive function battery. J Int Neuropsychol Soc. 2014;20(1):11-19. doi:10.1017/S1355617713001094
- Peters JH, Fried GM, Swanstrom LL, et al. ; SAGES FLS Committee . Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 2004;135(1):21-27. doi:10.1016/S0039-6060(03)00156-9
- Ochsner KN, Ray RD, Cooper JC, et al. . For better or for worse: neural systems supporting the cognitive down- and up-regulation of negative emotion. Neuroimage. 2004;23(2):483-499. doi:10.1016/j.neuroimage.2004.06.030
- Lang PJ, Bradley MM, Cuthbert BN. International Affective Picture System (IAPS): Affective Ratings of Pictures and Instruction Manual: Technical Report A-8. Gainesville: University of Florida; 2008.
- Leon AC, Davis LL, Kraemer HC. The role and interpretation of pilot studies in clinical research. J Psychiatr Res. 2011;45(5):626-629. doi:10.1016/j.jpsychires.2010.10.008
- Hays W. Statistics. 3rd ed New York, NY: CBS College Publishing; 1981.
- Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd ed Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
- Mazziotta J, Toga A, Evans A, et al. . A probabilistic atlas and reference system for the human brain: International Consortium for Brain Mapping (ICBM). Philos Trans R Soc Lond B Biol Sci. 2001;356(1412):1293-1322. doi:10.1098/rstb.2001.0915
- Tzourio-Mazoyer N, Landeau B, Papathanassiou D, et al. . Automated anatomical labeling of activations in SPM using a macroscopic anatomical parcellation of the MNI MRI single-subject brain. Neuroimage. 2002;15(1):273-289. doi:10.1006/nimg.2001.0978
- Wager TD, Davidson ML, Hughes BL, Lindquist MS, Ochsner KN. Neural mechanisms of emotion regulation: evidence for two independent prefrontal-subcortical pathways. Neuron. 2008;59(6):1037-1050. doi:10.1016/j.neuron.2008.09.006
- Lang PJ, Bradley MM, Fitzsimmons JR, et al. . Emotional arousal and activation of the visual cortex: an fMRI analysis. Psychophysiology. 1998;35(2):199-210. doi:10.1111/1469-8986.3520199
- Parker MJ, Manan A, Duffett M. Rapid, easy, and cheap randomization: prospective evaluation in a study cohort. Trials. 2012;13:90. doi:10.1186/1745-6215-13-90
- Creswell JD, Pacilio LE, Lindsay EK, Brown KW. Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress. Psychoneuroendocrinology. 2014;44:1-12. doi:10.1016/j.psyneuen.2014.02.007
- Kuyken W, Warren FC, Taylor RS, et al. . Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: an individual patient data meta-analysis from randomized trials. JAMA Psychiatry. 2016;73(6):565-574. doi:10.1001/jamapsychiatry.2016.0076
- Sen S, Kranzler HR, Krystal JH, et al. . A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557-565. doi:10.1001/archgenpsychiatry.2010.41
- Mayer SE, Lopez-Duran NL, Sen S, Abelson JL. Chronic stress, hair cortisol and depression: a prospective and longitudinal study of medical internship. Psychoneuroendocrinology. 2018;92:57-65. doi:10.1016/j.psyneuen.2018.03.020
- Grant F, Guille C, Sen S. Well-being and the risk of depression under stress. PLoS One. 2013;8(7):e67395. doi:10.1371/journal.pone.0067395
- Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proc Natl Acad Sci U S A. 2009;106(3):912-917. doi:10.1073/pnas.0807041106
- Mitchell DG. The nexus between decision making and emotion regulation: a review of convergent neurocognitive substrates. Behav Brain Res. 2011;217(1):215-231. doi:10.1016/j.bbr.2010.10.030
- Brosch T, Scherer KR, Grandjean D, Sander D. The impact of emotion on perception, attention, memory, and decision-making. Swiss Med Wkly. 2013;143:w13786.
- Broadbent DP, Causer J, Williams AM, Ford PR. Perceptual-cognitive skill training and its transfer to expert performance in the field: future research directions. Eur J Sport Sci. 2015;15(4):322-331. doi:10.1080/17461391.2014.957727
- Salas E, Rosen MA, Held JD, Weismuller JJ. Performance measurement in simulation-based training: a review and best practices. Simul Gaming. 2009;40(3):328-376. doi:10.1177/1046878108326734
- Hall JC, Ellis C, Hamdorf J. Surgeons and cognitive processes. Br J Surg. 2003;90(1):10-16. doi:10.1002/bjs.4020
- Anton NE, Bean EA, Hammonds SC, Stefanidis D. Application of mental skills training in surgery: a review of its effectiveness and proposed next steps. J Laparoendosc Adv Surg Tech A. 2017;27(5):459-469. doi:10.1089/lap.2016.0656
- Stefanidis D, Anton NE, Howley LD, et al. . Effectiveness of a comprehensive mental skills curriculum in enhancing surgical performance: results of a randomized controlled trial. Am J Surg. 2017;213(2):318-324. doi:10.1016/j.amjsurg.2016.10.016
- Mooneyham BW, Mrazek MD, Mrazek AJ, Schooler JW. Signal or noise: brain network interactions underlying the experience and training of mindfulness. Ann N Y Acad Sci. 2016;1369(1):240-256. doi:10.1111/nyas.13044
- McEwen BS, Morrison JH. The brain on stress: vulnerability and plasticity of the prefrontal cortex over the life course. Neuron. 2013;79(1):16-29. doi:10.1016/j.neuron.2013.06.028
- Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation: a possible prelude to violence. Science. 2000;289(5479):591-594. doi:10.1126/science.289.5479.591
- Durning SJ, Costanzo M, Artino AR Jr, et al. . Functional neuroimaging correlates of burnout among internal medicine residents and faculty members. Front Psychiatry. 2013;4:131. doi:10.3389/fpsyt.2013.00131
- Wenderoth N, Debaere F, Sunaert S, Swinnen SP. The role of anterior cingulate cortex and precuneus in the coordination of motor behaviour. Eur J Neurosci. 2005;22(1):235-246. doi:10.1111/j.1460-9568.2005.04176.x
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