Letter: Should Mindfulness be Incorporated as a Mandatory Component of Neurosurgical Training?

To the Editor: We believe burnout among neurosurgical trainees is an issue that requires further discussion and is in the interests of both patients and healthcare organizations to address. Mechanisms are already in place to offer help to trainees suffering from excessive work-related stress in the form of occupational health counselling services for example. However, we believe there needs to be more of a focus on providing trainees with resources to prevent burnout rather than cope with it once it has arisen. Surgeons are often compared with the stereotypical narcissistic, impulsive, and authoritarian doctors of days gone by.1 Indeed, the perception of the ‘typical surgeon’ has not significantly changed over time among physicians and students.2,3 Could it be the case that these qualities are developed among surgeons as coping strategies for excessive work-related stress? With the stakes of operating often perceived as being higher in neurosurgery, neurosurgical trainees in particular need not only to master the art of surgery but also to develop effective stress-management strategies in order to avoid burnout. The potential impact of surgeon burnout is enormous both for the surgeon and their patients and colleagues. Surgeons are reported to have some of the highest rates of marriage breakdown substance misuse and suicide rates among medics.4-6 It has been shown that there is a positive correlation between physician burnout and patient dissatisfaction and medical error-making.7,8 Incivility between colleagues as a result of excessive stress has been shown to increase team anxiety and reduce both parties’ short-term cognitive processing abilities and decision making.9 So why is more not being done to address the problem of burnout among surgeons? One study noted that there is a discrepancy between the perceived burden of excessive stress between seniors and trainees, with senior doctors underestimating the true prevalence of burnout.10 Perhaps there exists an unrealistic expectation that neurosurgical trainees universally have particularly high levels of resilience and tolerance for stress given the grit required to succeed as a neurosurgeon. Indeed, surgical specialties are under-represented in studies comparing rates of burnout between different specialty groups.11 One study found that surgeons represented only 4.3% (n = 44) of 1014 doctors presenting to a London-based health service which aims to support medics suffering from mental health issues and addiction.12 However, these results should be interpreted with caution as perhaps it is the aforementioned culture of surgery that prohibits an individual admitting to stress-related problems due to the perceived negative stigma of asking for help. If it is the case that neurosurgeons are less likely to admit that they are stressed, should the institutions responsible for training them not recognize this and, as a result, make more available alternative resources to help combat stress? Meditation has been practiced for thousands of years to focus the mind and overcome anxiety.13 The word ‘meditation’ often conjures up mental images of self-indulgent hippies, religious worship, prayer or even shamanistic rituals and so might therefore be overlooked by doctors skeptical of its relevance to the modern way of life. Mindfulness meditation, or simply ‘Mindfulness’, is the modern slant on this traditional practice. Rather than being portrayed as a path to spiritual enlightenment or divinity, its practice and perceived benefits are more aligned to the current understanding of psychology and mental wellbeing.14 It is defined as the pursuit of achieving a calm and focused mental state while increasing one's awareness of the present moment and acknowledging and accepting one's feelings, thoughts, and bodily sensations.15 Its popularity has sky-rocketed in recent years due to an ever-increasing body of scientific research backing its efficacy and growing accessibility in the form of mobile applications.16 Although difficult to blind participants in trials due to popular awareness of the techniques involved, mindfulness has not only been shown to help with psychological issues such as depression and anxiety, but also with somatic diagnoses such as hypertension, diabetes, and irritable bowel syndrome.17-19 Relevant to doctors, mindfulness has been shown to help reduce diagnostic errors and improves the quality of patient-doctor interactions.20-22 Despite knowing this, little has been done to formally integrate mindfulness into surgical training. A recent paper demonstrated that mindfulness-based stress reduction (MBSR) can be easily integrated into residency programs and was well received by participants, evidenced by low attrition, high attendance, and positive feedback.23 Another has shown that integration of MBSR has already been integrated into 31.8% of participating otolaryngology residency programs in the US where trainees are offered seminars in mindfulness and meditation.24 The Royal Australasian College of Surgeons has published an article promoting the use of mindfulness among surgeons.14 Going a step further, MBSR will become a mandatory component of accreditation standards in Canadian Oncology Residency programs as of 2018.25 Although not branded as such, mindfulness is already beginning to become integrated into formal surgical training in the UK. For example, the Nontechnical Skills for Surgeons (NOTSS) course endorsed by the Royal College of Surgeons of England highlights ‘situational awareness’ as one these important skills. Rather than one-off sessions, it has been shown that regular practice of mindfulness techniques is needed in order to reap the most benefit akin to learning surgical techniques on a repetitive basis over the course of training. Organization-directed interventions to combat stress have been shown to be more effective in reducing burnout and maintaining compliance among employees rather than allowing individuals to resource their own help.26 To conclude, it is apparent that more needs to be done and could be done by the neurosurgical training bodies across the globe to prevent trainees suffering from excessive stress, and in particular neurosurgical trainees, for their own benefit and also for their patients’. Mindfulness is an inexpensive and easily accessible method available to all. We should aim to breakdown cultural barriers and stigma that are associated with preventing mindfulness resources being incorporated into a healthy lifestyle and for providing an ambience for holistic training in Neurosurgery and other specialties. The provision of institutional subscriptions to, or internal development of, mindfulness applications would be a good starting point. We foresee a major benefit of incorporating mindfulness practice into the surgical curriculum to produce neurosurgeons who are optimally trained both in the technical and nontechnical skills of the job. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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