Can App-Based Mindfulness Reduce Physician Anxiety and Burnout?

RESEARCH UPDATE

In what seem like ancient times “BCV” (before coronavirus), there was a more slowly growing scourge for physicians and other health care workers: burnout. A study in 2011 reported that 38% of physicians had significant symptoms of burnout on a weekly basis, which increased to 48% in 2014 (nearly double that of the general working population), with current estimates reaching 90% for certain burnout components.^1,2 Burnout symptoms include inability to concentrate, irritability, exhaustion and cynicism among others.³

Institutional factors likely contribute to the significant increase in burnout. These include the introduction of electronic medical record systems, an emphasis on cost management, and an increasing movement to larger corporate structures, where physicians have found themselves progressively removed from their practices’ decision-making processes, including decisions pertaining to length of patient visits and treatment approaches.⁴

In addition to the movement to corporate-like conditions, the high demands of, and inherent uncertainty in, the practice of medicine itself may contribute to excessive worry, which is a core aspect of anxiety disorders.⁵ It is unclear whether anxiety predisposes physicians to burnout, is exacerbated by burnout, or the two interact to feed off of each other, yet several studies have found that mindfulness training, which has been shown to be effective at managing anxiety, decreases burnout in physicians.^6,7

Digital therapeutics are emerging as a new modality aimed at delivering behavioral treatments at low cost, broad availability, and with high fidelity. We tested whether an app-based mindfulness training (Unwinding Anxiety), which delivers short daily modules (~10 minutes/day) and just-in-time practices to help individuals learn to manage anxiety, could be effective for physicians, who report time demands as a major barrier to in-person mindfulness training.⁸

In this single-arm pilot feasibility study of anxious physicians (median baseline anxiety scores = 11.5 [moderate], measured by the Generalized Anxiety Disorder-7 scale, GAD-7), we found a strong correlation between anxiety and two measures of burnout (cynicism: r =.43, P = .01; emotional exhaustion: r =.71; P < .001, measured by the Maslach Burnout Inventory).⁹ GAD-7 scores decreased significantly at one and three months after physicians began using the app (one month: 48% reduction, P < .001; three months: 57% reduction, P < .001). Cynicism decreased by 50% (P = .009 at follow-up), and emotional exhaustion dropped by 20% (P = .003 at follow-up).

Clinical bottom line

While this was a small (n = 34), open-label trial, it suggests that app-based mindfulness training is feasible and may decrease anxiety and certain individual aspects of burnout (eg, cynicism). Unsurprisingly, burnout components such as exhaustion that are more institutionally driven are not going to be “fixed” by an app and require concerted and consistent advocacy to force change at the systems level-and to keep our doctors healthy and in the workforce. Future studies of app-based mindfulness for anxiety are required to prove efficacy; my lab is now completing a NIH-funded randomized controlled trial of the Unwinding Anxiety app for individuals with generalized anxiety disorder.

Press release from Brown University: https://www.brown.edu/news/2020-04-01/burnout

Funding

This study was funded by a Carl Akins Risk Management grant from the University of Massachusetts Memorial Medical Group.

Disclosures:

Dr Brewer is an addiction psychiatrist and neuroscientist, is the Director of Research and Innovation at Brown University’s Mindfulness Center, and an Associate Professor at Brown University’s Schools of Public Health and Medicine. Dr Brewer is the founder of MindSciences, the company that developed the mindfulness app used in this study. He owns stock in, serves as a non-compensated scientist for the company and has previously served on the board of directors. This financial interest has been disclosed to and is being managed by Brown University, in accordance with its Conflict of Interest and Conflict of Commitment policies. Follow him on Twitter @judbrewer.

References:

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.

2. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131-1150.

3. Gundersen L. Physician burnout. Ann Intern Med. 2001;135:145-148.

4. Southwick FS, Southwick SM. The Loss of a Sense of Control as a Major Contributor to Physician Burnout: A Neuropsychiatric Pathway to Prevention and Recovery. JAMA Psychiatry. 2018;75:665-666.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association Publishing; 2013.

6. Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int J Psychiatry. 2012;43:119-128.

7. Krasner MS1, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284-93.

8. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress Manag. 2005;12:164.

9. Roy A, Druker S, Hoge EA, Brewer JA. Physician Anxiety and Burnout: Symptom Correlates and a Prospective Pilot Study of App-Delivered Mindfulness Training. JMIR Mhealth Uhealth. 2020;8(4):e15608..