Mindfulness Practice for Surgeons

In 2017, American rock climber Alex Honnold climbed El Capitan, a 3000-foot-high granite wall in Yosemite National Park, without a rope, achieving a feat inconceivable to most. According to Honnold, intense preparation and a calm state of mind free of distraction were crucial to his success.1 Imagine if he became sidetracked by a bird flying overhead or a sudden thought of fear and doubt, both of which could have caused him to miss a step or a hand grip and fall. Although most people do not face such grave consequences for one fleeting moment of inattention, having an unfocused mind can lead to numerous negative effects. Daily, people are bombarded with "interferences"—distractions and interruptions, according to neuroscience. The constant notifications from cell phones, increasingly depressing stories on the news, and even one's own internal dialogue can lead to sensory and information overload. This in turn creates chaos, lack of calmness, and fear, resulting in disruptions in emotional regulation and even leading to mental illnesses. Individuals must be able to distinguish between relevant information and interferences, and then decide what to attend to immediately, what to set aside for later, and what to ignore altogether. Mindfulness practices help train individuals to become more aware of interferences and how to respond to them; it takes just 10 minutes each day to incorporate these into everyday life. The first section of this article discusses the neuroscience of interferences and how to recognize them. The second section teaches practical mindfulness skills that can help surgeons and scientists in their professional and personal lives. INTERFERENCES According to neuroscience literature, interferences can be divided into distractions and interruptions.2 Distractions are irrelevant information that should be ignored. Interruptions are events or thoughts that lead into a multitasking scenario, but only one task should have top priority. The source of both distractions and interruptions can be external or internal (Fig. 1). In the case of internal distractions and interruptions, attention is derailed from the task at hand and becomes focused on internal thought, either consciously or unconsciously. This is referred to by many terms, including "mind-wandering," "self-generated thought," "spontaneous cognition," and "spontaneous fluctuations of attention."2Fig. 1.: Examples of distractions and interruptions.Why are interferences so detrimental for surgeons and why is it so important to learn to regulate them? Research in neuroscience has demonstrated repeatedly that interferences are detrimental to task performance and memory.3 Lack of regulation can lead to impairments in cognition and social conduct; affect regulation; and even increase risk of mental illnesses, including depression, anxiety, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and substance use.3 On any given workday, surgeons have many tasks to accomplish and obligations to balance, including clinical work, research, teaching, and administrative tasks, and also leave enough time for self-care and personal relationships. Surgeons also need to maintain focus during challenging physical and mental tasks, such as during a microvascular anastomosis. Interferences can sneak in at any given moment and divert the attention from the primary task. A study from New Zealand recorded the frequency of distractions that occurred in the operating room.4 The researchers found that a distracting event occurred as frequently as every 106 seconds and that 23% of distracting events affected the entire surgical team. In fact, distractions in the operating room are implicated as the most significant contributing factor in up to 50% of surgical errors. Furthermore, perfectionist personality traits may predispose surgeons to impatience, frustration, and anger. Less experienced surgeons are also more likely to be affected by interferences, suggesting that training on how to recognize and cope with stressors and distractions is best started as early in training as possible.5 Although it is impractical and impossible to eliminate all interferences, equipping surgeons with the skills to identify and regulate them by means of mindfulness practices can be immensely beneficial. THE EVOLUTION OF MINDFULNESS Mindfulness is deeply rooted in Buddhist traditions of meditation. The word "mindfulness" traces back to the Pali word sati, which means "to remember," "to recollect," and "to bear in mind."6 It implies awareness, attention, alertness, and insight cultivated by meditation. Historically, mindfulness was practiced only by Buddhist monks, but in recent decades, it has been practiced by many and without a need for religious affiliation. The practice was introduced to the United States in the 1960s when Buddhist missionaries emigrated to the country. One of the most prominent figures who made mindfulness accessible to the general population was Jon Kabat-Zinn,7 who was introduced to meditation by a Zen missionary and subsequently established a formal mindfulness course at the University of Massachusetts Medical School in 1979. This eventually transformed into guided meditation recordings that can be accessed at home. Today, mindfulness is defined simply as the process of being present with whatever we are doing or surrounded by, without judgment.7 It is not only used in medicine to treat mental illnesses, but many highly successful individuals, such as Bill Gates, practice mindfulness as well. It can also be taught in a group setting to enhance athletic performance. For example, the Seattle Seahawks hired a mindfulness coach during the season they won the Super Bowl in 2014. Equipped with skills to stay in the present moment and maintain clarity of thought, mindfulness ultimately played an important part in their win.8 The benefits of mindfulness are backed by neuroscience and medicine. Studies have shown that mindfulness reduces the size and activity of the amygdala, which is the emotional center of the brain that regulates stress, fear, and anxiety.9 In addition, it has been demonstrated that long-term meditators possess an increased amount of gray matter, which is responsible for emotional regulation, planning, and problem-solving. HOW TO PRACTICE MINDFULNESS The goal of a daily mindfulness practice is, simply, to become more present. The goal is not to fight or eliminate interferences and negative thoughts, but to learn to respond to them in a productive way. A good analogy for dealing with interferences is to treat them as passing clouds—you see them, take note of them, and let them float by.10 Observing interferences without judgment ultimately leads to a gradual decrease in one's identification and involvement in intrusive and distracting thoughts.11 Starting a mindfulness routine does not require a lot of time each day, but it does require dedication and a strong desire for it to make a positive impact.12 There is not one formula that fits everyone. Many individuals may find themselves trying different techniques and routines before finding one that fits into their life. It can take days to weeks to make mindfulness a daily habit. The easiest way is to start practicing 5 to 10 minutes per day and gradually increasing the amount of time. Mindfulness can be practiced any time of day, but it is usually easiest to do so early in your day when it is quiet and there are few distractions.12 Beginners also find it useful to use audio and visual guides with cell phone apps such as Headspace, Calm, Insight Timer, and 10 Percent Happier. Once the habit of practicing mindfulness is established, one can begin to incorporate it at various moments throughout the day. For surgeons, it can be done at the scrub sink, before a meeting, during the time between seeing clinic patients, or while riding the subway to work. During such moments, it takes just a few minutes to refocus the mind and practice any of the techniques highlighted later in this article. Ultimately, the goal is to naturally practice mindfulness throughout the day. The purpose is to give focus to each task, whether they are significant or mundane, without interferences, so that each task is carried out with intention. This will help the mind be more aware of the external environment and internal thoughts, so that when interferences arise, one is able to identify them and turn his or her attention back to the present moment. Figure 2 illustrates some examples of how to incorporate this at work and at home.Fig. 2.: Examples of how to incorporate mindfulness into small moments at work and at home.Techniques in Mindfulness Practice Deep Breathing Deep breathing is the most common technique used in mindfulness and it is often the one people learn first. It serves as the foundation for all other techniques. Numerous studies in psychology have shown that controlled deep breathing can have positive physiologic and psychological responses.11 Recall a time when you dealt with a patient who was in distress or a great amount of pain; one of your first instructions to the patient was probably to take slow, deep breaths. Indeed, controlled deep breathing decreases resting heart rate, increases the parasympathetic response, dampens the sympathetic nervous system, and leads to stress reduction. Not only does deep breathing have these profound short-term and immediate effects, it also can lead to greater feelings of happiness, satisfaction, and connection to others in the long term.13 For surgeons, during stressful parts of an operation when you may find yourself holding your breath or getting anxious, deep breathing can be especially useful. It is a fast and effective way to regain control and restore a sense of calm. To practice deep breathing, start by finding a position that is comfortable, either sitting or lying down. The eyes can be open or closed, or a soft gaze can be maintained. Slowly take breaths in through the nose and out through the mouth. Focus attention on various aspects of the breathing, such as the rise and fall of the chest, or inhaling the cool air and exhaling the warm. It is normal to notice the mind occasionally becoming distracted by sounds, sensations, or thoughts. It is important to try not to get frustrated when the mind wanders, but simply make a mental note of it happening and try to gently return the focus back to the breath. Body Scan The body scan technique involves focusing attention sequentially on various body parts. This promotes increased bodily awareness and triggers a variety of behavioral adaptations.11 Body scan can be practiced while sitting up or lying down. Starting at the top of the head, slowly focus attention down the body to the shoulders, arms, torso, legs, and feet. Make a mental note of any sensations or feelings that arise at each spot on the body. For example, the temperature of the skin, muscular tension, eyelid movement, moisture of the tongue, or points of contact with the floor. It is tempting to place judgment on the sensations and identify them as pleasant or painful. However, the key to this practice is to refrain from judging the sensations and to simply note their existence before moving on to the next body part. Mental Noting Mental noting is the practice of labeling experiences and emotions as they arise. Differing from other techniques, mental noting directs the thinking mind to do something. Mental noting redirects thinking into a rudimentary form so the mind does not wander.14 The technique aims to create space in the mind and help individuals learn about their habits, tendencies, and emotions. Examples include: On hearing a sound, note "hearing" without thinking further about the sound. On feeling a painful sensation, note "pain" without trying to eliminate or change it. Emotions can be labeled "anxious," "happy," "fear," "sad," and so forth. Mental activity can be labeled as "wishing," "planning," "thinking," and so forth. It is important to distinguish mental noting from thinking. Thinking inherently involves judging and analyzing. For instance, imagine a situation where the sponge count is off at the end of a 12-hour operation. It is already 9 o'clock at night, and you are hungry and tired. The brain may generate an emotional response of frustration because, in the worst case scenario, you have to reopen the incisions to retrieve the sponge. The thinking brain is easily triggered in these situations and may start to assign blame, either to yourself or another member of the team. However, this is counterproductive and may cause ripples in the team relationship. Instead, when practicing mental noting, the mind simply labels the emotion as "frustration" and prevents the thinking brain from reacting further. As a result, the individual is no longer hyperreactive based on his or her emotions and is able to create space in the mind to respond to the situation in the most productive and harmonious way. Guided Imagery Guided imagery, also referred to as visualization or mental rehearsal, is a technique that uses all five senses (vision, taste, smell, touch, and sound) to create a mental image of a task or environment. Numerous studies have demonstrated the efficacy of guided imagery in its ability to reduce pain in cancer patients, improve quality of sleep, modulate stress, and optimize performance.15 When they begin practicing guided imagery, many people find it useful to visualize and recreate a pleasant memory10—such as recalling a pleasant experience or location—and slowly start to reconstruct images of this positive memory by incorporating all five senses. Once you are able to recreate a memory, you can then begin to construct images that involve the future, dreams, and life goals.10 Many athletes use guided imagery as a part of their training. For example, Alex Honnold reported that he practiced visualization before free soloing El Capitan.1 He would imagine different sections of the climb, what the foot and hand holds are like, and how it feels to be in certain positions. He said that rehearsing his moves in this way prepared his mind to be ready for any emotions that might arise during the climb, so nothing would be a surprise.1 This technique can be especially useful for surgeons when preparing for operations or trainees learning a new technique. One can practice visualizing each step of an operation and the potential challenges encountered during each. As a result, when challenges occur during the procedure, the surgeon will have already anticipated these scenarios and prepared his or her mind to respond in a calm manner. Resting in Awareness Differing from the other techniques, resting in awareness allows the mind to rest without the pressure to do anything. The techniques previously mentioned in this article instruct the mind to focus on certain bodily sensations and feelings to prevent it from reacting to interferences. Resting in awareness goes one step beyond the framework built by the other techniques; in fact, it abandons the framework altogether.16 According to Kabat-Zinn, when practicing resting in awareness, one no longer chooses a focus for awareness, but instead, allows the focus to have no bounds "since awareness actually is, and always has been boundless."16 This method, however, requires practice because in untrained minds, awareness tends to contract and the mind has a tendency to fixate on certain moments or thoughts, especially those that evoke a strong emotion.16 In a guided meditation using the method of resting awareness, Kabat-Zinn says the practice can be achieved through multiple gradual steps, each representing an expansion of the field of awareness.16 For example, first allow the awareness to feature sound. Next, the field of awareness can be expanded to the air, to sensations in the body, to thoughts that arise. In a final step, the field of awareness expands to include all the senses and becomes infinite with no boundaries. At this final step, Kabat-Zinn emphasizes that, instead of focusing on anything specific, the mind should be allowed to rest without pursuing or rejecting anything.16 It is also in this final state that the mind will sense any changes that arise. Even if these changes provoke discomfort in the body or harbor negative emotions, the awareness can embrace such feelings without judgment. Ultimately, the goal of practicing mindfulness is to be able to embrace any thoughts or distractions that arise without judgment. It is beneficial for surgeons to incorporate mindfulness into a daily routine. Surgeons can even use techniques such as visualization to hone their surgical skills. However, most importantly, mindfulness can teach surgeons to be more in tune with the external environment and their internal thoughts. The result is a surgeon who is more productive and empathetic. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and a research grant from Sonex to study carpal tunnel outcomes. Dr. Tang has no financial relationships or conflict of interest to report. ACKNOWLEDGMENTS The authors would like to thank Meghan Cichocki for contributions to the development of this writing; and Mike Stokes, staff vice-president of communications at the American Society of Plastic Surgeons, for the peer review and edits.