Physician Well-

being: Strategies for

Increasing Resilience

in the COVID Era

Personal Skills to Thrive

Lifestyle choices as levers for greater health and well-being

Ruth DeBusk, PhD, RD, Managing Partner, MBNsystems in collaboration with the Office of Personalized Health and Well-being (PHW), Director, Cathy Snapp, PhDMedical College of Georgia AU/UGA Medical PartnershipDirector, Behavioral Health St. Mary’s and PAR Internal Medicine Residency Programs

Session Objectives

Understanding inner coherence to strengthen applied well-being through research-based tools and practices:

Explain the role of autonomic balance within the gut-brain-heart axis in generating inner balance and how this state promotes health and resilience

Discuss the role of genomics and epigenetics in promoting autonomic balance and well-being

Discuss the role of positive emotion on neural networks for: increased resilience and energy, lasting behavioral change and its potential for changing behavior that helps sustain well-being.

List just one thing that can be done today to promote autonomic balance and well-being.

\

“Purposeful trained attention is used to decrease negative thoughts and bring greater focus on the most meaningful aspectof an experience.”

Ahmet Sood, MD, executive director of the Global

Center for Resiliency and Well-being; formerly Professor

of Medicine at the Mayo Clinic in Rochester, Minnesota

Key to Physician Well-being

Training

Strategy #1. Provide the medical learner with the underlying mechanisms of well-being

“Tell me the “what” and the “how” of physician well-being and I

will be so much more open to actually doing the practices”.

PGY1 Resident

St. Mary’s Internal Medicine Residency, University of Georgia

Gut/Heart/Brain Axis

Neural

Tissue

Sympathetic/

Parasympathetic

Balance

ANS

Balance -

Flexibility/

Resilience

Positive

Neuroplasticity

Well-being

Lifestyle

Choices

“Nutriture” Gene

Expression

Positive

Emotion

Focused

Attention

Increased:

Mental clarity

Sleep quality

Immune resilience

Memory & Learning

Creativity

Wound healing

Habits of positivity

Self-care

Self-compassion

Quality of life

Decreased:

Inflammation

Oxidative stress

Medical error

Low energy, focus

Lifestyle

Choices

Nutritional Genomics Fundamentals

Genes Proteins Function

Bioactives Metabolites

Genomics and Epigenetics

Genomics

Epigenetics

Genes Protein Function

Messages “talking” to the genes

Food

Physical Activity

Thoughts & Emotions

Relationships

Sleep & Restoration

NFkB and Epigenetic Regulation

Liu T, et al., Signal

Transduct Target Ther.

2017;2:e17023.

Curcumin

Resveratrol

Phenotype

Soft

Drinks

Exercise

Physician Well-being

What does it mean to you?“Now that I see these connections, I am really excited to learn tools and techniques to fill my tank…so as I navigate the challenges of residency, I might not get so depleted.”

PGY1 Internal Medicine Resident

Strategy #2 Focusing attention on core strengths

“Well-being is developed by learning to train one’s attention on more positive aspects of life”. (Sood, 2018)

Learning about identifying core inner strengths/neural “parking places” that restore and build our energy through the VIA CHARACTER STRENGTHS

Free and open sourced: www.VIACHARACTER.org

Strategy #3 Positive Emotion and Lifestyle Choices

Purposeful trained attention is used to decrease negative thoughts and bring greater focus on the most meaningful aspect of an experience.

(Sood, 2018)

Upward Spiral Theory of Lifestyle

Change

Nonconscious

Motives

for Health

Behaviors

Engagement in

Health Behaviors

Built Resources:

Biological &

Psychological Positive Affect

During Health

Behaviors

Model articulated by the upward spiral theory of lifestyle change (Fredrickson, 2013; Van Cappellen et al., 2017).

Mindfulness

Positive Emotion

Neuroplasticity

• Mindfulness broadens awareness and builds eudaimonic meaning: A process model of mindful positive emotion regulation (Garland, E. L., Farb, N. A., R. Goldin, P., & Fredrickson, B. L. , 2015)

• Positive Emotions and neural networks of attention: Gupta R. Positive emotions have a unique capacity to capture attention. Prog Brain Res. 2019;247:23-46. doi: 10.1016/bs.pbr.2019.02.001. Epub 2019 Mar 1. PMID: 31196436.

• Fixing our focus: Training attention to regulate emotion (Wadlinger, H. A., & Isaacowitz, D. M. 2010)

• Upward spirals of positive emotions counter downward spirals of negativity: Insights from the broaden-and-build theory and affective neuroscience (Garland, E. L., Fredrickson, B. L., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. L. 2010)

• Feeling good: Autonomic nervous system responding in five positive emotions (Shiota, M. N., Neufeld, S. L., Yeung, W. H., Moser, S. E., & Perea, E. F. 2011)

• Stress reduction correlates with structural changes in the amygdala (Hölzel, B. K., Carmody, J., Evans, K. C., Hoge, E. A., Dusek, J. A., Morgan, L., … Lazar, S. W., 2010)

• Mindfulness practice leads to increases in regional brain gray matter density (Hölzel, B. K., Carmody, J., Vangel, M., Congleton., C., Yerramseti, S. M., Gard, T., & Lazar, S. W., 2011)

• Memory reconsolidation, emotional arousal and the process of change (Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L., 2015)

• Motivated encoding selectively promotes memory (Oyarzún, J. P., Packard, P. A., de Diego-Balaguer, R., Fuentemilla, L., 2016)

• Positive Emotion for Post-traumatic growth (Wei C, Han J, Zhang Y, Hannak W, Dai Y, Liu Z. Affective emotion increases heart rate variability and activates left dorsolateral prefrontal cortex in post-traumatic growth. Sci Rep. 2017 Nov 30;7(1):16667.

18

Physical

Activity

Nature

Strengths

And

Positive

Emotion

Leading to BURNOUTCrosswell AD, Moreno PI, Raposa EB, Motivala SJ, Stanton AL, Ganz PA, Bower JE. Effects of mindfulness training on emotional and physiologic recovery

from induced negative affect. Psychoneuroendocrinology. 2017 Dec;86:78-86. doi: 10.1016/j.psyneuen.2017.08.003. Epub 2017 Aug 4. PMID:

28923751; PMCID: PMC5854159.

Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, Souza T, Gonçalves AK. Burnout syndrome among medical residents: A systematic

review and meta-analysis. PLoS One. 2018 Nov 12;13(11):e0206840. doi: 10.1371/journal.pone.0206840. PMID: 30418984; PMCID: PMC6231624.

Littman-Ovadia H, Russo-Netzer P. Prioritizing positivity across the adult lifespan: initial evidence for differential associations with positive and negative emotions. Qual Life Res. 2019

Feb;28(2):411-420. doi: 10.1007/s11136-018-2012-3. Epub 2018 Sep 25. PMID: 30255375.

Fredrickson BL, Joiner T. Reflections on Positive Emotions

and Upward Spirals. Perspect Psychol Sci. 2018

Mar;13(2):194-199. doi: 10.1177/1745691617692106.

PMID: 29592643; PMCID: PMC5877808.

High Cardiac Vagal Tone

Measured through Heart

Rate Variability

McCraty R, Zayas MA. Cardiac coherence, self-regulation, autonomic stability, and psychosocial well-being. Front

Psychol. 2014 Sep 29;5:1090. doi: 10.3389/fpsyg.2014.01090. PMID: 25324802; PMCID: PMC4179616.

Laborde S, Mosley E, Mertgen A. A unifying conceptual framework of factors associated to cardiac vagal control. Heliyon. 2018

Dec 8;4(12):e01002. doi: 10.1016/j.heliyon.2018.e01002. PMID: 30623126; PMCID: PMC6313821.

McCraty R, Shaffer F. Heart rate variability: new perspectives on physiological mechanisms, assessment of self-regulatory capacity, and health risk. Glob Adv Health Med (2015) 4(1):46–61.

McCraty R, Zayas MA. Cardiac coherence, self-regulation, autonomic stability, and psychosocial well-being. Front

Psychol. 2014 Sep 29;5:1090. doi: 10.3389/fpsyg.2014.01090. PMID: 25324802; PMCID: PMC4179616.

Training our

purposeful attention

to bring greater focus

on the most

meaningful aspect of

an experience.” Dr. Ahmet Sood

McCraty, R. New Frontiers in Heart Rate Variability and Social Coherence

Research: Techniques, Technologies, and Implications for Improving Group

Dynamics and Outcomes Frontiers in Public Health (2017)

Messaging System

RED GREENPhysiological Response

Nutrition

Relationships

Thoughts & Emotions

Physical Activity

Sleep & Restoration

Personal Health Continuum

Putting it into PracticeJust One Thing JOT

Small doable action steps

they choose

and are excited about

Key Studies

– Positive

Emotion

and

Autonomic

Balance

Impact of a Workplace

Stress Reduction

Program on Blood

Pressure and Emotional

Health in

Hypertensive Employees

Rollin McCraty, Ph.D.,

Mike Atkinson, and Dana

Tomasino, B.A.

Journal of Alternative and

Complementary Medicine.

2003; 9(3): 355-369.

Abstract

Objectives: This study examined the impact of a workplace-based stress management program (Heart-

Math) on blood pressure (BP), emotional health, and workplace-related measures in hypertensive employ-

ees of a global information technology company.

Design: Thirty-eight (38) employees with hypertension were randomly assigned to a treatment group that

received the stress-reduction intervention or a waiting control group that received no intervention dur-

ing the study period. The treatment group participated in a 16-hour program, which included instruction

in positive emotion refocusing and emotional restructuring techniques intended to reduce sympathetic

nervous system arousal, stress, and negative affect, increase positive affect, and improve performance.

Learning and practice of the techniques was enhanced by heart rate variability feedback, which helped

participants learn to self-generate physiological coherence, a beneficial physiologic mode associated with

increased heart rhythm coherence, physiologic entrainment, parasympathetic activity, and vascular reso-

nance. BP, emotional health, and workplace-related measures were assessed before and 3 months after

the program.

Results: Three months post-intervention, the treatment group exhibited a mean adjusted reduction

of 10.6 mm Hg in systolic BP and of 6.3 mm Hg in diastolic BP. The treatment group also demonstrated

improvements in emotional health, including significant reductions in stress symptoms, depression, and

global psychological distress and significant increases in peacefulness and positive outlook. Furthermore,

the trained employees demonstrated significant increases in the work-related scales of workplace satisfac-

tion and value of contribution.

A Controlled Pilot Study of

Stress Management

Training of Elderly Patients

with Congestive

Heart Failure

Frederic Luskin, PhD, Megan

Reitz, BA, Kathryn Newell,

MA, Thomas Gregory Quinn,

MD, William Haskell, PhD.

Preventive Cardiology

2002;5(4):168-172, 176.

Abstract

The purpose of this study was to evaluate the effect of stress management training on quality of life, func-

tional capacity, and heart rate variability in elderly patients with New York Heart Association class I-III con-

gestive heart failure (CHF). While substantial research exists on stress management training for patients

with coronary heart disease, there are few data on the value of psychosocial training on patients with CHF.

Thirty-three multiethnic patients (mean age, 66±9 years) were assigned through incomplete randomiza-

tion to one of two treatment groups or a wait-listed control group. The 14 participants who completed

the treatment attended eight training sessions during a 10-week period. The training consisted of 75-min-

ute sessions adapted from the Freeze-Frame stress management program developed by the Institute of

HeartMath. Subjects were assessed at baseline and again at the completion of the training. Depression,

stress management, optimism, anxiety, emotional distress, and functional capacity were evaluated, as

well as heart rate variability. Significant improvements (p<0.05) were noted in perceived stress, emotional

distress, 6-minute walk, and depression, and positive trends were noted in each of the other psychoso-

cial measures. The 24-hour heart rate variability showed no significant changes in autonomic tone. The authors

noted that CHF patients were willing study participants and their emotional coping and functional

capacity were enhanced. This program offers a simple and cost-effective way to augment medical man-

agement of CHF. Given the incompleteness of CHF medical management and the exploding interest in

complementary medical intervention, it seems imperative that further work in psychosocial treatment be

undertaken.

Emotional Self-Regulation

Program Enhances

Psychological Health and

Quality of Life in Patients

with Diabetes

Rollin McCraty, Ph.D., Mike

Atkinson, and Lee Lipsenthal,

M.D. HeartMath Research

Center, Institute of

HeartMath,

Publication No. 00-006.

Boulder Creek, CA, 2000.

Summary

Aims:This pilot study was designed to assess changes in psychological status, quality of life and hemato-

logic measures predictive of long-term health and well-being in patients with diabetes following a stress

reduction and emotional self-regulation program.

Methods: Twenty-two patients with Type 1 or Type 2 diabetes mellitus participated in a 2-day HeartMath

workshop, a research-based program developed to reduce stress and negative affect, increase positive

affect and reduce inappropriate autonomic nervous system activation. Self-report measures of stress, psy-

chological status and quality of life were administered before and six months following the intervention.

Hemoglobin A1c, cholesterol and triglycerides, and blood pressure were also assessed.

Results: Participants experienced significant reductions in psychological symptomatology and negative

emotions, including anxiety, depression, anger and distress, following the intervention. Significant increas-

es in peacefulness, social support and vitality were also measured, as well as reductions in somatization,

sleeplessness and fatigue. Participants showed reduced sensitivity to daily life stressors after the inter-

vention, and quality of life significantly improved. Regression analysis revealed a significant relationship

between self-reported practice of the techniques learned in the program and the change in HbA1c levels

in patients with Type 2 diabetes. Increased practice was associated with reductions in HbA1c.

Conclusions: Results suggest that the HeartMath emotional self-regulation intervention reduces stress,

improves psychological health, enhances quality of life and may improve glycemic control in individuals

with diabetes. Replication of this study with a non-treatment control group is necessary to confirm these

findings.

The Effect of a

Biofeedback-based Stress

Management Tool on

Physician Stress:

A Randomized Controlled

Clinical Trial

Jane B. Lemaire, Jean E.

Wallace, Adriane M. Lewin,

Jill de Grood, Jeffrey P.

Schaefer

Open Medicine 2011;

5(4)E154.

Background: Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

Objective: To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

Design: Randomized controlled trial measuring efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

Setting: Urban tertiary care hospital.

Participants: Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians’ lounge and throughout the hospital.

Intervention: Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

Main outcome measure: Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

Results: During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001).

Conclusion: A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

Coherence: A Novel

Nonpharmacological

Modality for Lowering Blood

Pressure in

Hypertensive Patients

Abdullah A. Alabdulgader,

D.C.H., M.R.C.P., A.B.P.,

F.R.C.P., Saudia Arabia.

Global Advances in Health

and Medicine 2012; 1(2):54-

62; www.gahmj.com.

Abstract

This study examined the efficacy of teaching emotional self-regulation techniques supported by heart rhythm

coherence training (emWave Personal Stress Reliever) as a means to quickly lower blood pressure (BP) in patients

diagnosed with hypertension. Previous studies have demonstrated systemic reductions in BP in both high stress

populations and patients diagnosed with hypertension using this approach, but to the best of our knowledge, an

investigation of their ability to produce immediate reductions in BP had not been published in the medical literature.

The study was a randomized controlled design with 62 hypertensive participants who were divided into three groups.

Group 1 was taking hypertensive medication, was taught self-regulation technique, and used heart rate variability

coherence (HRVC) training devices. Group 2 was not yet taking medication and was trained in the same intervention.

Group 3 was taking hypertensive medication but did not receive the intervention and was instructed to relax

between the BP assessments.

An analysis of covariates was conducted to compare the effectiveness of three different interventions on reducing

the participants’ BP. The use of the self-regulation technique and the HRVC-monitoring device was associated with a

significantly greater reduction in mean arterial pressure in the two groups who used the intervention as compared

with the relaxation-plus-medication group. Additionally, the group not taking medication that used the intervention

also had a significantly greater reduction in systolic BP than the relaxation- plus-medication group.

These results suggest that self-regulation techniques that incorporate the intentional generation of positive emotions

to facilitate a shift into the psychophysiological coherence state are an effective approach to lowering BP. This

approach to reducing BP should be considered a simple and effective approach that can easily be taught to patients

to quickly lower their BP in stressful situations. The technique should be especially useful when hypertensive

patients are experiencing stressful emotions or reactions to stressors. It is possible that the BP reductions associated

with the use of the technique leads to a change in the physiological set-point for homeostatic regulation of BP.

Further studies should examine if large scale implementations of such heart-based coherence techniques could have

a significant impact on reducing risk of mortality and morbidity in hypertensive patients.

Mayo Clinic Hospital, Arizona –

Leadership Resilience and Stress

Reduction

Building Personal and

Professional Resources of

Resilience and Agility in the

Healthcare Workplace:

Teresa Britt Pipe, Vicki L. Buchda,

Susan Launder, Barb Hudak, Lynne

Hulvey, Katherine E. Karns & Debra

Pendergast Nursing Administration,

Mayo Clinic Hospital, Phoenix, AZ,

USA, 2011;

Stress Health, Wiley Online

Library, DOI: 10.1002/smi.1396.

Abstract This article describes the rationale, implementation and results of a pilot study evaluating the personal and organizational impact of an educational intervention on the stress of health team members. The compelling imperative for the project was to find a positive and effective way to address the documented stress levels of healthcare workers. Pilot study of oncology staff (n = 29) and healthcare leaders (n = 15) exploring the impact of a positive coping approach on Personal and Organizational Quality Assessment‐Revised (POQA‐R) scores at baseline and 7 months using paired t‐tests. Personal and organizational indicators of stress decreased in the expected directions in both groups over the time intervals. The majority of POQA‐R categories were statistically significantly improved in the oncology staff, and many of the categories were statistically significantly improved in the leadership group. The findings from this project demonstrate that stress and its symptoms are problematic issues for hospital and ambulatory clinic staff as evidenced by baseline measures of distress. Further, a workplace intervention was feasible and effective in promoting positive strategies for coping and enhancing well‐being, personally and organizationally.