translating the evidence about mind-body medicine into practice: barriers and issues in training
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Translating the evidence about mind-body medicine into practice: Barriers and issues in training. Victor S. Sierpina, M.D. W.D. and Laura Nell Nicholson Family Professor of Integrative Medicine Professor, Family Medicine University of Texas Medical Branch. Co-Investigators. Ruth Levine, MD - PowerPoint PPT PresentationTRANSCRIPT
Translating the evidence about mind-body medicine into practice: Barriers
and issues in training
Victor S. Sierpina, M.D.W.D. and Laura Nell Nicholson Family Professor of
Integrative MedicineProfessor, Family Medicine
University of Texas Medical Branch
Co-Investigators
Ruth Levine, MDProfessor of Psychiatry
University of Texas Medical Branch
John Astin, PhDSenior Scientist
California Pacific Medical CenterSan Francisco, CA
Alai Tan, MD, PhDAssistant Professor
Office of BiostatisticsDepartment of Preventive Medicine and Community Health
University of Texas Medical Branch
Developmental Project 4
Barriers to Translation of Mind-Body Therapies to Training and Practice in Family Medicine and
Psychiatry
Victor S. Sierpina, M.D., Ruth Levine, M.D. John Astin, Ph.D.
• This project will identify barriers to evidence-based, mind-body medicine being regularly taught in training or implemented into practice
Developmental Project 4—Aims
• To survey residents and faculty at UTMB in family medicine and psychiatry programs comparing specialty responses.
• Introduce mind-body skills groups and training into both family medicine and psychiatry residencies.
• Perform a subsequent national survey of family medicine and psychiatry residency program directors and chief residents
Working hypotheses
• A number of specific factors can be identified that block the integration of MBM into patient care.
• Personal exposure to MBM techniques and experiences will improve the acceptance of these methods among clinicians.
Barriers To Translation Model
• Informed by qualitative, quantitative studies and literature review
• Survey designed around identified items from focus groups*
*{Astin JA, Goddard T, Forys K. Barriers to the integration of mind-body medicine: Perceptions of physicians, residents and medical students. EXPLORE: The Journal of Science and Healing. 2005}
From Research to Health Outcomes:
Translation Blocks to Mind-Body Medicine
CLINICAL RESEARCH CONTINUUM
Basic Science Research
Translation from Basic Science to Human Studies
Attitudes to Use/Validity of MBM
Translation Block
Personal psychological factors, need for control
Education, Culture, and Belief System
Personal transformationalexperiences
Peer support, medical culture
Practice environment, time demands
Patient expectation
Self efficacy, expectation of positive outcome
Variables
Clinical Science and Knowledge
Translation of New Knowledge Into Clinical Practice and Health Decision Making
Clinical Trials of MBM
Peer support, medical culture
Practice environment, time demands
Patient expectation
Self efficacy, expectation of positive outcome
•Attitudes to Use/Validity of MBM
•Clinical Practice of MBM
•Referral to MBM PractitionersVariables
Improved Health
Previous findings—Astin’s National Survey
• 1/3 of physicians acknowledged importance of psychosocial issues but doubted addressing them would make much difference in health outcomes
• A minority believed they had effective training in these areas or desired more
{Astin, et al. J Am Bd Fam Prac in press, 2006}
Barriers
• Poor training
• Lack of self-efficacy/control
• Lack of knowledge of evidence base
• Inadequate time/reimbursement
{Astin, et al. J Am Bd Fam Prac in press, 2006}
Mind Body Medicine methods explored in current survey
• Biofeedback• Guided imagery• Hypnosis• Meditation• Relaxation therapies• Yoga and Tai Chi
Not specifically inquired about:
• Cognitive behavioral therapy
• Psychoeducational approaches
Gender Difference in the use of MBM
5.4
62.2
32.4
13.5
75.7
10.8
0
10
20
30
40
50
60
70
80
Often Sometimes Never
Variables
Per
cent
age
Male Female
0
10
20
30
40
50
60
70
80
90
High Belief FM High Belief PSY
Assessment of MBM Approaches
Anxiety
Depression
0
10
20
30
40
50
60
High FM High PSY
MBM Approaches in Treating Various Disorders
Irritable Bowel
Fibromyalgia
Hypertension
Low Back Pain
0
20
40
60
80
FM Greatly PSY Greatly
Contributes
Factors that Limit Physician's Interest in Using MBM
InadequateReimbursement
Poor Training
Lack of expertise
Absence of qualifiedpractitioners
Insufficient clinic time
0
10
20
30
40
50
60
FM Greatly PSY Greatly
Contributes
Factors that Limit Physician's Interest in Using MBM - Cont'd
Absence of demonstrablyeffectiveness
Lack of acceptance amongpeers
Resistance of patients
Concern that patients feelbeing discounted
Summary of findings
• There was little difference between physicians’ responses in the two specialties
• Substantial reports that barriers to the use of MBM were largely based on lack of training, inadequate expertise, and insufficient clinic time
• Lack of expertise and insufficient clinic time were higher among family physicians than psychiatrists
• There was a high interest in both groups in learning relaxation techniques and meditation and lower interest in biofeedback and hypnosis
Summary of Findings
• Female physicians significantly more likely to utilize MBM in both their own self-care and with patients
• Female physicians less likely to be concerned that recommending these therapies would make patients feel that their symptoms were being discounted
• Female physicians also had significantly higher beliefs about the benefits of MBM on health disorders than males in several of the conditions examined, with a consistent, though non-significant trend in others.
• A mental focusing device
• A passive attitude to distracting thoughts
• Deep, relaxed, abdominal breathing
{Benson H, Stuart E. The Wellness Book, 1992}
The Relaxation Response
1. Focus word
2. Sit quietly in comfortable position
3. Close your eyes
4. Relax muscles
5. Breath slowly, naturally, repeat focus word
6. Assume passive attitude
7. Continue 10-20 minutes
8. Daily practice9. When distracting
thoughts occur, return to focus word, breathing
Steps to eliciting the Relaxation Response
Stress Survival Strategies for Stress Survival Strategies for Health Care Professionals and Health Care Professionals and
PatientsPatientsVictor S. Sierpina, MDVictor S. Sierpina, MD
Nicholson Professor of Integrative MedicineNicholson Professor of Integrative MedicineDepartment of Family MedicineDepartment of Family Medicine
UTMBUTMB
Some intrinsic stressors in Some intrinsic stressors in MedicineMedicine
StaffingStaffing SchedulingScheduling Time pressuresTime pressures Diagnostic Diagnostic
challengeschallenges MalpracticeMalpractice
Sleep deprivation Sleep deprivation and shift workand shift work
PTSDPTSD Role ambiguity Role ambiguity
among residentsamong residents Depressed Depressed
immunityimmunity
Patient related stressorsPatient related stressors
Communication issues with patients and Communication issues with patients and their families, verbal abusetheir families, verbal abuse
ViolenceViolence Exposure to infection: hepatitis, AIDS, Exposure to infection: hepatitis, AIDS,
SARS, MRSA, DRE, other “bug du jour”SARS, MRSA, DRE, other “bug du jour” Drug seekersDrug seekers Social, financial problems of patientsSocial, financial problems of patients
What Can Be Done About What Can Be Done About Stress?Stress?
Biological interventionsBiological interventions Psychological interventionsPsychological interventions Social interventionsSocial interventions
Personal/social stress resilience Personal/social stress resilience approachesapproaches
Music listening and Music listening and music makingmusic making
Self reflectionSelf reflection Spiritual well-being, Spiritual well-being,
prayer, religious prayer, religious practicepractice
MassageMassage Essential oilsEssential oils Cognitive Cognitive
behavioral behavioral strategiesstrategies
BiofeedbackBiofeedback HumorHumor Mindfulness based Mindfulness based
stress reductionstress reduction PsychodramaPsychodrama ImageryImagery Relaxation therapiesRelaxation therapies
Some Simple TechniquesSome Simple Techniques
Deep breathingDeep breathing
Progressive Muscle relaxationProgressive Muscle relaxation
MusicMusic
MeditationMeditation
Future studies
• National survey of FM and Psych Residency Directors and Chief Residents (IRB review of revised on-line survey in progress)
• Evaluation of impact of MBM training on FM and Psych residents personal and professional practices (proof of concept to follow pilot)
• Focus on how MBM training can help programs attain competencies in Professionalism
Manuscripts produced
• Sierpina V, Levine R, Astin J, Tan A. Use of Mind-Body Therapies in Psychiatry and Family Medicine Faculty and Residents: Attitudes, Barriers, and Gender Differences. Explore: The Journal of Science and Healing {under review—2006}
Manuscripts produced
• Sierpina V, Astin J, Giordano J. Behavioral and Mind-Body Therapies for Migraine and Tension Headaches. Am Fam Phys {under review—2006}
• Astin JA, Soeken K, Sierpina VS, Clarridge BR. Barriers to the integration of psychosocial factors in medicine: Results of a national survey of physicians. J Am Bd Fam Pract. {in press-2006}
Reference manuscripts
• Astin JA, Goddard T, Forys K. Barriers to the integration of mind-body medicine: Perceptions of physicians, residents and medical students. EXPLORE: The Journal of Science and Healing. 2005;1 (4):278-283.
• Astin J. Mind-body medicine: State of the science, implications for practice. J Am Bd Fam Pract. 2003;16:131-147
Acknowledgement
Supported by grants from the National Institutes of Health:
• Mind-Body Exploratory and Development Grant #1 R21 AG023951-01 from National Institute of Aging and Office of Biobehavioral and Social Science Research (VSS)
• #R01 AT00869-04 from the National Center for Complementary and Alternative Medicine (JA)
• CAM Education Grant #1 R25 AT00586-01 from National Center for Complementary and Alternative Medicine (VSS)