January 2017 VOL 8, NO 1

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AONN+ Annual Meeting

Stop, Breathe, Reflect: Practicing Mindfulness in Medicine

Practicing mindfulness in medicine has positive effects on both providers and the patients they care for, according to John Inzerillo, MD, Medical Director of Oncology at Marion L. Shepard Cancer Center in Washington, NC.

Mindfulness is a mental state achieved by focusing one’s awareness on the present moment and calmly acknowledging any feelings, thoughts, and physical sensations accompanying that moment. According to Dr Inzerillo, promoting present awareness appears to reduce automatic negative self-evaluation, increase tolerance for negative effect and pain, and helps to engender self-compassion and empathy in chronically dysphoric individuals. “We may not all be chronically depressed, but we all cycle; the difference is how high are the highs and how low are the lows,” he said. “The more mindful we can be, the closer we can stay to the center,” he told attendees in a keynote address at the Academy of Oncology Nurse & Patient Navigators 7th Annual Navigation & Survivorship Conference.

In short, shifting the attention from a cognitive to a sensory focus is beneficial to improving one’s sense of well-being. To achieve that shift, he suggests simply imagining your attention moving from the brain, down to the heart. “Consciously take yourself away from thinking and go towards feeling,” he advised. “It sounds like magic, but we can all achieve it; it’s just a practice.”

Mindfulness in Daily Practice

Mindfulness is a combination of awareness, attention, and insight. “There’s more to it than we understand, but awareness is what we focus on, and the more we focus on an issue, the more we can develop insight,” he said. Part of the practice is developing one’s own insight (ie, the ways in which we individually respond to a patient’s needs).

Dr Inzerillo stressed the importance of taking a moment to breathe when feeling rushed or anxious at work. “We’re always in our heads thinking about all the things we have to deal with—the patient on the phone or in front of us, our family members, a conference coming up—but connecting with our breath will bring us back to the present,” he said. “Before seeing a patient, I like to get my chart, stand at the door, and take a breath to set myself up for what’s to come next.”

We all bring our work home with us to a certain extent. But focusing on the breath and bringing oneself back to the present changes the thought process, and actually changes the physiology in the brain. We’re confronted with choices all the time, and choosing to be mindful is one of those choices. “But the more time you put into the practice of being mindful, the better you get,” he said, noting that mindfulness is about being aware of the present moment without judging it, “because often it’s how we judge a situation that makes us feel the way we feel.”

Oncology isn’t an easy discipline, and when dealing with a difficult patient, he said to consider where that person is coming from rather than becoming frustrated. Ask yourself, “Would I act the same way in this situation?” “When someone gets cancer, the whole family is affected,” he added. “Everyone has a role, and when that role is disrupted because of cancer, everything falls onto who’s left.”

He asked the audience to listen to their patients. Let them finish what they’re saying, and don’t interrupt them. He encouraged mindfulness of the voice, as well as the breath, since patients can hear exhaustion and frustration behind our words. He stressed attention to posture and the importance of sitting down with patients, even when in a rush. “As you get more wound up, so do the people around you,” he said. “Then everything is in disarray.”

He offered a brief summary of breathing techniques from the teachings of Pranayama and Vipassana meditation, and affirmed that mindfulness isn’t just for fatigued caretakers. Among patients with breast and prostate cancer, the practice has been shown to reduce inflammatory cytokines and cortisol. It also reduces relapse and recurrence of major depression compared with treatment as usual, while reducing patients’ stress symptoms.

Mindful coping strategies engage wider neural networks than suppression. In other words, you’re using more of your brain, more effectively, when in a mindful state. As evidenced in functional MRIs, the practice of mindfulness regulates amygdala functioning by way of the medial prefrontal cortex, and the deep breathing stimulates the parasympathetic nervous system. Conversely, emotional suppression (ie, “What I think doesn’t matter, I’m too busy for that so I’ll just ignore it) is associated with activity of the dorsolateral prefrontal cortex and promotes exaggerated sympathetic activity that can affect the immune response and physical health. “Twenty years ago we knew this by experience, but we didn’t have evidence,” he said. “Now we do.”

Mindfulness and Compassion

Compassion is a willingness to recognize the suffering of another coupled with the desire to help relieve such suffering. “We all suffer, and someone with cancer has to deal with their diagnosis on top of daily living,” said Dr Inzerillo. “None of us even know if we’ll make it home tonight. But that’s part of being mindful and living right now, because that’s all we have.”

He urged the audience to remember compassion in their daily interactions with patients, since undue stress can negatively impact their cancer treatment. He advised looking at patients as teachers, appreciating what stands to be learned from them, and looking at the learning experience as an opportunity to become more effective. Providers can help cancer patients by bringing compassion to patient care by simply listening to them and taking the time to figure out what’s bothering them.

He encouraged attendees to ask themselves simple questions to keep their mindfulness and compassion in check, questions like “How high is my anxiety level today?” “How is my sense of ease?” “How much time did I spend living in the now today?” “How much time did I spend looking to place blame?” Dr Inzerillo explained, “When we’re not blaming, we can find out where the errors are and make corrections. It’s good to plan, but it’s not good to try to live in the past or future.”

He emphasized the importance of letting go of old ideas and assumptions, material objects, relationships, and even our own health. As we get older there will be arthritis, and there might even be prostate cancer or breast cancer with bone metastases. “There is going to be pain, but by using mindfulness we can let go of that pain to a degree,” he said.

Cancer drugs are going to keep changing, and 2 to 5 years from now there will be a new set of drugs with new toxicities. But according to Dr Inzerillo, “when it comes to mindfulness and presence, you’ll have that for the rest of your life.”

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