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.

MBM/Stress Management Curriculum

• SNAPSHOT VIEW

• 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)