Five Practical Video Modules to Reduce Physician Burnout Through Mindfulness and Systematic Review of Evidence

Summary:

Burnout, characterized as depersonalization, emotional exhaustion, and a sense of reduced personal efficacy, is an ongoing problem faced by surgeons and medical trainees at all levels of training. Increasing evidence suggests that mindfulness interventions are effective in reducing burnout and stress among healthcare providers. With a goal to build our own programs, we sought to evaluate the evidence on mindfulness interventions among physicians and trainees. What we found went beyond a systematic review and has advanced our practices to a larger understanding of the interconnectivity between mindfulness, meditation, emotional intelligence, and leadership. In this article, we outline mindfulness and published interventions including their efficacy in reducing physician burnout and stress through a systematic review of randomized controlled trials (32 trials published between 2011 and 2023). In 4 distinct modules including 5 supplemental video modules, concepts that promote mindfulness are reviewed, providing a foundation for a mindfulness practice. These video modules include: (1) what mindfulness and meditation are, (2) a 5-minute meditation, (3) the Institute for Professional Excellence in Coaching energy leadership strategy, (4) building resilience through emotional intelligence, and (5) translating mindfulness into practice. This special topic aimed to open the conversation among plastic surgeons about burnout and the role that mindfulness can have to reduce its negative effects on our practices and our lives.

Takeaways

Question: Burnout, characterized as depersonalization, emotional exhaustion, and a sense of reduced personal efficacy, affects surgeons and trainees. What is the quality of evidence and practical resources to begin mindfulness to reduce burnout in the practicing surgeon?

Findings: The systematic review of randomized controlled trials illustrates effectiveness of mindfulness among physicians and trainees across course types, technologies, delivery models, and durations of training suggesting that it is the underlying practice of mindfulness, and not the structure of the course or intervention, that is truly effective.

Meaning: In 5 distinct supplemental video modules, concepts that promote mindfulness are reviewed, providing a foundation for a mindfulness practice.

INTRODUCTION

Physician stress and burnout are growing global concerns that negatively impact the fidelity of healthcare systems. Burnout is precipitated by progressive exposure to stress¹ and manifests as depersonalization, emotional exhaustion (EE), and a diminished sense of professional efficacy.² Physician burnout is associated with an increased risk of substance abuse,³ addiction, and suicide,⁴ and reduced patient satisfaction, lower quality of care, and higher rates of medical error.^3,4 Surgeons are particularly affected by burnout,^5–7 precipitated by challenges with work-life balance, long work hours, and workplace mistreatment.⁸ Nationally, departments are developing approaches to reduce burnout among their surgeons and surgical trainees.⁸

Burnout became particularly evident during the COVID-19 pandemic, affecting 63% of physicians in the United States,⁹ 53% in Canada,¹⁰ and 13%–74% of primary care physicians younger than 55 years of age in 10 high-income countries.¹¹ However, increasing awareness of burnout and criticism of the current healthcare system preceded the pandemic and was a topic of consideration within plastic surgery for nearly a decade,^12–15 including systems characterized by a 2019 New York Times article as the exploitation of doctors and nurses through their duty to care for others in systems under strain.¹⁶ In 2019, the Institute of Medicine published a landmark report Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being.¹⁷ It was a critical follow-up to patient safety and quality of care reports, outlining systems-based approaches to improve the safety, health, and well-being of healthcare providers. The emphasis of the report included the dramatic changes in technology, regulation, policy, and societal trends occurring in healthcare systems and the importance of organizational change to reduce healthcare provider burnout.

A survey of pubmed.gov-indexed publications illustrates the increasing discussion of physician burnout in the medical literature (Fig. 1). Outside of organization change, individual efforts including mindfulness interventions have gained interest as an effective practice to reduce burnout in healthcare providers¹⁸ with a parallel increase in publications. Interestingly, despite the challenges of surgical residency and practice, there is relatively little published on the usefulness of mindfulness among surgeons (Fig. 2).

Fig. 1.

Pubmed.gov publications on physician burnout (red) and mindfulness (blue), 1981–2023. Publications suggest that mindfulness could be an intervention for burnout (courtesy of Susan Mackinnon).

Fig. 2.

A pubmed.gov search of publications on mindfulness and healthcare professionals, 1981–2023, by study population (courtesy of Susan Mackinnon).

The usefulness of mindfulness interventions in healthcare workers was recently well characterized during the COVID-19 pandemic.¹⁹ We sought to evaluate the effect of mindfulness interventions specifically in physicians using a systematic review of randomized controlled trials (RCTs) including medical trainees, residents, and physicians/surgeons. This article distills useful concepts of mindfulness presented in 5 video modules to enable plastic surgeons to pursue their own mindfulness journey and create lasting improvements in surgical culture: (1) mindfulness, (2) meditation, (3) Institute for Professional Excellence in Coaching (iPEC) energy leadership strategy, (4) building resilience, and (5) translating mindfulness into practice.

MODULE 1: MINDFULNESS

A Systematic Review and Meta-analysis of Mindfulness Interventions in Physicians and Trainees

The systematic review is reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. (See appendix 1, Supplemental Digital Content 1, which shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 checklist, https://links.lww.com/PRSGO/E110.) The protocol was prospectively registered with Open Science Framework (https://doi.org/10.17605/OSF.IO/B9K82). Appendix 2 includes the complete methodology for the systematic review and meta-analysis. (See appendix 2, Supplemental Digital Content 2, which shows systematic review methodology, (https://links.lww.com/PRSGO/E111.) RCTs in English-language peer-reviewed journals evaluating the effect of mindfulness interventions on validated measures of burnout and stress among physicians, residents, and trainees were included. The population, intervention, comparison, outcomes, and study design tool framework guided eligibility for systematic review. Interventions included any mindfulness-based program promoting mindfulness content compared with a control group (eg, placebo, waiting list, or active interventions) in a population of medical students, residents, or physicians. Studies that included mindfulness as a secondary component of an intervention (eg, yoga) were excluded. All validated burnout and stress outcome measures were extracted based on a priori criteria; however, the most commonly used burnout measure in the literature, the Maslach Burnout Inventory (MBI)²⁰ comprised of EE, depersonalization, and personal accomplishment subscales, was used preferentially in the meta-analysis when multiple measures were included in a study. Stress was reported using the Cohen Perceived Stress Scale (PSS-10 or PSS-14). A random-effects meta-analysis of standardized mean differences in baseline mean and follow-up stress and burnout scores was performed using Review Manager (Version 5.4). A subanalysis was performed on studies without a high risk of bias and on studies comparing mindfulness-based stress reduction (MBSR) (the most common validated mindfulness course) and non-MBSR interventions. The quality of meta-analyses was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. Statistical analysis for effect size, data heterogeneity, and publication bias was assessed using PythonMeta (version 1.26) (Supplemental Digital Content 1, https://links.lww.com/PRSGO/E110; Supplemental Digital Content 2, https://links.lww.com/PRSGO/E111).

Results of Systematic Review and Meta-analysis

A total of 32 RCTs of 3047 participants (1613 intervention and 1434 control) were reviewed for the effect of mindfulness interventions in physicians and trainees (2081 articles identified, 1042 duplicates removed, 1039 screened, and 96 full-text reviewed) (Fig. 3).

Fig. 3.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of study identification and selection.

Identified RCTs on physician mindfulness interventions are relatively recent; all were published between 2011 and 2023, and more than half (16 of 32) were published between 2021 and 2023, during the COVID-19 pandemic. More than half of the studies were conducted in the United States (52.9%) (Fig. 4), and most trials were conducted in residents (13 studies, 2 in surgical residents) and medical students (12), with only 7 in attending physicians and 1 RCT specifically including attending surgeons with surgical residents. (See appendix, Supplemental Digital Content 3, which shows study characteristics of included studies and a description of interventions, https://links.lww.com/PRSGO/E112.)

Fig. 4.

World map of RCTs of mindfulness interventions in physicians, residents, and/or medical students, 2011–2023.

Mindfulness Interventions

Mindfulness is awareness of one’s internal thoughts and surroundings achieved by paying purposeful attention to the present moment. Kabat-Zinn et al²¹ created the MBSR program in the 1980s for individuals with chronic pain, and his work is the foundation for many interventions in healthcare workers and physicians.

There is a diversity of mindfulness interventions in RCTs that reduce burnout between physicians and trainees (Table 1). Mindfulness interventions were delivered using in-person courses, technology solutions (apps), virtual courses, and hybrid. Eighteen (56.3%) studies delivered interventions in-person. Half of all studies (15 of 32) used or adapted the MBSR program, traditionally an in-person intervention.⁵³ MBSR is a comprehensive 8-week program of weekly training classes, daily homework, and a social retreat to reinforce mindfulness.⁵³ Other mindfulness courses included Attention and Interpretation Therapy, Better Together, and Compassion Cultivation Training, and some made changes in content (eg, including resiliency training). A common theme among all interventions was altering awareness through meditation. In-person interventions typically lasted 8 weeks (range 2 d to 9 mo). All in-person interventions included classes teaching mindfulness techniques and modules on themes related to mindfulness, ranging from 1 to 2.5 hours, and were usually weekly (12, 66.7%).^{22–34,39,46,51,52} Thirteen in-person interventions^{22,24–28,30,31,39,51,52,54} explicitly included at-home self-guided practice (5–45 min/d) or homework. Eight of the in-person interventions included a social retreat.^{22,24,25,27–29,54}

Table 1.

Mindfulness Interventions in RCTs of Physicians, Residents and Medical Students, 2011–2023

Category of Intervention	Intervention Title and Description
In-person interventions	MBSR22–25: 8 weekly 2–2.5-h sessions. The mindfulness component includes body scan, yoga stretches, and meditation (breathing, observing thoughts, and walking meditation). Includes an 8-h retreat and daily formal home practice
	Adapted MBSR26–28: 6 or 8 weekly shorter or 2-h sessions, including 1.5-h meditation, with an emphasis on resilience training. Includes a similar or shorter duration retreat or no retreat, and daily less-formal practice
	Mindful Medicine Curriculum29: 13-h weekend training course based on MBSR. It includes added compassion skills training, brief mindfulness techniques to be used at work, and the application of mindfulness to speaking, listening, and observing
	Stress Management and Resiliency Training program30,31: Single 90-min small group session based on AIT. PowerPoint slides about AIT plus brief structured relaxation intervention (paced breathing meditation) 5–15 min/d
	Mindfulness Intervention for New Interns32: Seven 1-h sessions of mindfulness curriculum (social lunch, 1 min of silence, introduction to mindfulness, a mindfulness exercise, debrief) and monthly mindfulness refresher (prerecorded 10-min body scan exercise)
	Facilitated physician discussion groups33
	Cognitive therapy and acceptance and commitment therapy34: Adapted from MBSR, 10-wk mindfulness training
Technology interventions	Biofeedback device35: Rhythmic breathing, self-generated positive emotions, and a portable biofeedback device to reduce stress
	“Dear Doctor” text messages36: Text messages delivered to physician devices based on 11 evidence themes in 6 categories: gratitude, self-efficacy, connection to purpose, social support, support resources (including mindfulness and self-compassion), and planning
	Mindful awareness practices framework37: 5 weekly sessions delivered on a mobile application and online forum
	Coresights Virtual Reality application38 Weekly 10-min virtual reality–guided meditation (including paced breathing and mindfulness meditation)
	HeadSpace application39–45: Adapted MBSR* delivered through the application or the Compassion Cultivation Training Program† also delivered through application
Virtual or hybrid virtual–in-person interventions	Adapted MBSR using video modules45
	In-person mindfulness session* audio CD46: Two 60-min guided sessions for relaxation, attention, and clarity. Daily 30-min audio-guided meditation for 8 wk
	Compassion Cultivation Training Program47: 8 weekly 2-h virtual group sessions to learn “6 essential steps” “1) learning to focus and settle the mind; 2) experiencing compassion and loving-kindness for a loved one; 3) experiencing compassion and loving-kindness for oneself; 4) experiencing compassion towards others, premised in common humanity and interconnectedness; 5) experiencing compassion towards all beings; and 6) ‘active compassion’ practice.”
	Mindfulness-based intervention48: Ten 35-min virtual classes twice weekly, plus 10-min yoga (breathing and posture) and dietary advice
	Better Together49,50: Live virtual 60-min group coaching calls led by physician coaches (Life Coach School), and self-study or 4 monthly didactic webinars
	Hybrid in-person and Headspace application51: In-person practice sessions, a mindfulness retreat, plus the Headspace application for independent practice
	Integral Meditation52: 10 online classes (35 min) twice weekly, 10 min of yoga before each class, dietary advice, and independent practice

^*Yang et al,⁴¹ Hicks et al,⁴² and Boden et al.⁴³

^†Cooper et al.⁴⁰

AIT, Attention and Interpretation Therapy.

Fourteen studies (43.8%) were online or virtual (eg, mobile applications, audio recordings, and text messaging). The 14 virtual interventions ranged from 1 day to 10 months in duration. Seven studies were group-based virtual sessions using an online platform. The MBSR program was adapted for virtual delivery, an adaptation of the study to the COVID-19 pandemic, and for the Headspace application, and continued to show efficacy. In the virtual modifications of the MBSR, all previously in-person classes were moved to virtual, and there was no retreat. The most common virtual intervention studied was the Headspace application, which guides daily 10- to 20-minute mindfulness exercises (8 of 14).^39–45,51 Virtual interventions were frequently delivered daily (6 of 14). Virtual interventions improved stress and burnout among participants; however, due to study method heterogeneity, a meta-analysis comparing in-person to virtual was not possible.

Meta-analysis

From 32 RCTS, 21 had fully extractable data and were analyzed in the meta-analysis (Supplemental Digital Content 3, https://links.lww.com/PRSGO/E112). Eighteen studies (662 intervention versus 684 control; 1346 total participants) were included in the analysis of the impact of mindfulness interventions on burnout at 1 week or less, 2–4 weeks, and 12 weeks or more (Fig. 5). Mindfulness-based interventions significantly reduced burnout at all timepoints with a statistically significant improvement between all timepoints (<1, 2–4, and ≥12 wk; P = 0.03) (Fig. 5A). Similarly, 14 studies with 1067 total patients (514 intervention versus 553 control) significantly reduced validated stress scores at all timepoints; scores between timepoints did not significantly differ (<1 wk, P < 0.0001; 2–8 wk, P < 0.0001; and ≥12 wk, P = 0.002; between timepoints P = 0.62) (Fig. 5B).

Fig. 5.

Random-effects meta-analysis evaluating the efficiency of mindfulness-based interventions on burnout (A) and stress (B) in a pooled population of medical students, residents, and physicians. A, Random-effects meta-analysis evaluating the efficacy of mindfulness-based interventions on burnout at 1 week or less, 2–4 weeks, and 12 weeks or more of follow-up. B, Random-effects meta-analysis evaluating the efficacy of mindfulness-based interventions on stress at 1 week or less, 2–8 weeks, and 12 or more weeks of follow-up. CI, confidence interval; IV, inverse-variance.

The efficacy of MBSR and non-MBSR interventions was evaluated at less than 1 week for both burnout and stress (Fig. 6). Both were effective in reducing burnout (MBSR, −0.29 [−0.58, −0.01], I² = 67%, P = 0.02; non-MBSR, −0.22 [−0.41, −0.03], I² = 0%, P = 0.05) with no statistical subgroup differences (P = 0.67). Similarly, both MBSR (−0.46 [−0.67, −0.25], I² = 21%, P < 0.0001) and non-MBSR interventions (−0.29 [−0.51, −0.08], I² = 0%, P = 0008) significantly reduced stress and were statistically indistinguishable (P = 0.27).

Fig. 6.

Random-effects meta-analysis subgrouping MBSR and non-MBSR interventions for burnout (A) and stress (B) at 1 week or less in a pooled population of medical students, residents, and physicians. A, Random-effects meta-analysis subgrouping MBSR and non-MBSR interventions for burnout at 1 week or less. B, Random-effects meta-analysis subgrouping MBSR and non-MBSR interventions for stress at 1 week or less. CI, confidence interval; IV, inverse-variance.

Quality and Strength of Evidence

The most frequently reported time windows (<1-wk postintervention and >12 wk) yielded a moderate Grading of Recommendations, Assessment, Development, and Evaluation of evidence with low to moderate heterogeneity (0%–44%) for nearly all outcomes (Supplemental Digital Content 3, Table 4, https://links.lww.com/PRSGO/E112). Publication bias was not present for burnout (P = 0.402) or stress (P = 0.408). Risk of bias 2 was used to evaluate the risk of bias. A limitation in assessing the risk of bias was the difficulty of blinding participants to a mindfulness intervention. Single blinding of the assessor was consistently performed; however, most participants were unblinded to the mindfulness intervention, and 85% of studies used a passive control group (a waitlist). Only studies that used an active control group were deemed to be at low risk of bias. Our results were insensitive to the exclusion of studies with a high risk of bias based on risk of bias 2; mindfulness reduced burnout in 11 studies (P = 0.04 to <0.0001) and stress in 10 studies (P = 0.02 to <0.0001) across all timepoints, consistent with the main analysis. (See appendix 4, Supplemental Digital Content 4, which shows secondary meta-analyses, https://links.lww.com/PRSGO/E113.) Mindfulness was studied more often in medical students; only 3 studies included surgeons: 2 in surgical residents and 1 in both surgical residents and attending surgeons, which represents a limitation. To evaluate whether the effect of mindfulness was influenced by the stage of training, an additional meta-analysis was performed for residents and attending physicians, excluding medical student studies, and showed reduced stress and burnout at less than 1 week and more than 12 weeks after the intervention. There is limited evidence evaluating the impact of mindfulness beyond 1 year. Finally, the MBI, the most common evaluation tool for burnout, was intended for use across organizations and not to measure changes in an individual, a major limitation of most studies on mindfulness interventions. There is the added concern about causality: given the complexity of burnout, changes in burnout after a mindfulness intervention can, at best, be considered a correlation, and inferring a causal relationship is prone to error^55,56 (Supplemental Digital Content 4, https://links.lww.com/PRSGO/E113).

MODULE 1 VIDEO: WHAT IS MEDITATION AND MINDFULNESS?

Burnout continues to be an international problem among physicians, including surgeons. Plastic surgeons are not immune, with roughly 30% experiencing burnout. (See Video 1 [online], which shows a summary overview of the problem of burnout among physicians, the publication rate of mindfulness interventions for the reduction of burnout, and why considering mindfulness to reduce burnout is important.)^13,57 Recent publications have emphasized the importance of reducing burnout and have included mindfulness practices as a potential solution⁵⁸; however, there are currently no high-quality studies or RCTs among plastic surgeons investigating mindfulness for burnout reduction. In clinical research, mindfulness practices reduce salivary cortisol and blood pressure along with a reduction in perceived stress,⁵⁹ and brain plasticity.⁶⁰ In the broader literature on physicians and trainees, including this systematic review, mindfulness interventions are associated with reduced stress and burnout, with known limitations, and may represent a starting point for burnout prevention. RCTs illustrated an effect regardless of in-person or virtual courses including physician populations around the globe. This systematic review also illustrates effectiveness across course types, technology, delivery, and duration suggesting that it is the underlying practice of mindfulness, and not the structure of the intervention, that is important. Where should individual surgeons start?

Barriers to the implementation of a formal, organization-supported mindfulness course may exist influenced by the organizational culture, practice structure, and policies of a health workplace.⁶¹ Organizational readiness to support a resource-intensive formal mindfulness course, such as the MBSR, is a critical first step when evaluating the practicality of introducing a course as a tool for burnout. However, mindfulness does not need to be organizationally supported, or a structured course, or even a formal practice of sitting quietly for 20 minutes, but rather a practice of increasing awareness, being in the moment and aware of the “thought conversation" that constantly runs through our head, and choosing to take a pause (Table 2). Although mindfulness practices are simple, they are not easy to master. Various techniques of mindfulness (breathing, body scan, and loving-kindness) are strategies to create daily pauses and increase self-awareness.^62–64 The loving-kindness meditation included in the MBSR framework is just 1 tool in a burnout toolkit, but we have found it particularly useful.⁵³ In recent years, others have attempted to capture the themes of MBSR in modified programs or virtual applications. Importantly, interventions that follow the original MBSR program and those that modify the MBSR or use non-MBSR programs are effective at reducing stress and burnout. This suggests a wide range of delivery methods for achieving effective mindfulness (see Video 1 [online]).

Table 2.

A 5-minute Pause for Awareness

Let’s try a 5-min pause for awareness and being present in the moment

Sit dignified, hands on lap, spine erect, eyes closed, or soft gaze downward

A cycle of breath (inhale/exhale) to the count of 5 takes 10 s, 3 breaths can create a pause and some space to allow you to make a conscious response rather than an unconscious reaction

1. Put your awareness on your thoughts, don’t engage with the thoughts, just notice the thoughts. Imagine your brain like the sky, and the thoughts are clouds just drifting across. Become the watcher of your thoughts—no judgment, just observing them and letting them go, drifting across your mind like clouds across the sky

2. Now, take your awareness to what you’re hearing; does it seem different from 1 ear to the other? Notice the sounds in the room, the sounds outside the room, and focus your awareness on what you’re hearing

3. Now, move your awareness to your breath. On the inhale, imagine the breath moving from the bottom of your spine all the way up to the top of your head, and then on the exhale, imagine that breath coming down from the top of your head, slowly descending the spine to your pelvis. Focus your awareness on that loop of breath moving up and down your spine. Slow the breath down: inhale for 4 counts, exhale for 4 counts. Put your awareness on the space between the inhale and the exhale at the top of the breath cycle. Breathe through your nose, slowing the breath down. Thoughts may come into your head, let them go without attaching to the thoughts, no judgment, gently come back to the breath. Do 5 cycles of breath: inhale slowly, exhale slowly 5 times

4. Now, imagine that loop of breath, making a circle through your body. On the inhale, imagine the breath moving from the bottom of your feet, up your legs, your pelvis, your belly, chest, and head, and then on the exhale, imagine the breath looping down through your body. Follow the inhale as it moves up, and then follow the exhale as it moves down; do 5 cycles of breath, putting your awareness on the breath, moving up and then moving down your body

5. Now, continue to expand the breath within your whole body, creating a balloon of breath. With every inhale and exhale, make that balloon bigger; imagine your skin thinning out and imagine the space you’re creating filling that balloon with molecules and atoms and space

6. Now, expand that breath, so it fills the whole room, then the whole house, the whole building, the city you’re in, the province or state you’re in, the country, and then blends into the space of the universe. After 5 breaths, collect all your atoms and molecules and return to your body

Video 1. This video shows a summary overview of the problem of burnout among physicians, the publication rate of mindfulness interventions for the reduction of burnout, and why considering mindfulness to reduce burnout is important.

Download video file ^{(56.4MB, mp4)}

MODULE 2: 5-MINUTE MEDITATION

As a resource to plastic surgeons, we include a 5-minute guided meditation as a starting point to discover meditation and mindfulness. (See Video 2 [online], which shows a guided meditation that is just less than 5 min. Guided meditation is a component of nearly all mindfulness interventions, and this video is both an example of a guided meditation and a tool that readers can use to practice meditation.) Meditation is a practice that leads to mindfulness, allowing us to create awareness in the moment and make a conscious choice rather than follow an otherwise default response based on learned beliefs, assumptions, and interpretations. The way into mindfulness is through increasing awareness through breathing⁶⁵ (Table 2). In general, there are 3 types of meditation practices: (1) breathing and body scanning, (2) observing thoughts, and (3) loving-kindness (Table 3). The inhale drives the sympathetic system (flight, fight, and freeze), and the exhale drives the parasympathetic system through the vagus nerve (rest and relaxation). In his book Breath, Nestor⁶⁶ expands on this topic, and the epilogue provides several breathing practices. Kabot-Zinn²¹ (mindfulness), Tolle⁶⁷ (spiritual enlightenment), Chödrön⁶⁸ (loving-kindness), and Brach⁶⁹ (radical compassion) provide a way into meditation science. We include a 5-minute practice to increase awareness (Table 2), and a sample of loving-kindness meditation (Table 3) (see Video 2 [online]).

Table 3.

A Sample of Loving-kindness and Self-compassion Meditation

This is a 4-line prayer/mantra  1. may you be free of pain and suffering  2. may you be free of fear and anxiety  3. may you find peace and calm  4. may you find happiness and joy

You start this practice by saying that prayer for someone you love and loves you unconditionally. Conjure their image and essence, breathe in their love for you, and breathe out your love for them. Repeat this several times. This will feel wonderful.

The next step is to say that same prayer/mantra for yourself. This will probably feel awkward. Continue to practice this until it feels wonderful, practicing loving-kindness and self-compassion for yourself.

The third step is to make it a practice to do this throughout your day; we have lots of opportunity at our work to say this prayer for neutral people whom we notice are struggling or suffering as we move through our day at the hospital. Practice this prayer for family and friends who may be suffering too. Try this exercise at night before you go to sleep.

The final step is to practice this prayer for those “very disagreeable people.” When you do this, with true forgiveness and compassion, for those who have hurt you, you were letting go of the painful drama, anger, and negativity that increases your adrenaline and cortisol, and shortens your telomeres. The neural transmitters associated with compassion, kindness, peace, calm, happiness, joy, and love (dopamine, gamma-aminobutyric acid, serotonin, oxytocin, anandamide) are healthy for us.

Video 2. This video shows a guided meditation that is just under 5 minutes. Guided meditation is a component of nearly all mindfulness interventions, and this video is both an example of a guided meditation and also a tool that readers can use to practice meditation.

Download video file ^{(57.3MB, mp4)}

MODULE 3: IMPROVING LEADERSHIP SKILLS THROUGH COACHING

Few things are more accessible than meditation when considering personal changes that can reduce the experience of burnout. (See Video 3 [online], which describes the Institute for Professional Excellence in Coaching energy leadership strategy, developed by Schneider,⁷⁰ that reframes experiences and emotional reactions to improve interactions and promote performance.) We propose the following mindfulness toolkit for combating burnout as physicians and healthcare professionals:

Video 3. This video describes the Institute of Professional Excellence in Coaching (iPEC) energy leadership strategy, developed by Bruce Schneider, that reframes experiences and emotional reactions to improve interactions and promote performance.

Download video file ^{(46.9MB, mp4)}

• Maximize meaning in your job.

• Meditation builds mindfulness. Mindfulness builds resilience.

• Practice self-kindness:

  • -Self-compassion
  • -Being in the moment
  • -Increasing self-awareness of our emotions so others’ emotions and thoughts do not burn us out (Table 2).
  • -To take some time to heal ourselves.

• As leaders, practice mindfulness as a component of the job (Table 3).

• As teachers, role model self-compassion and well-being.

Two articles included in the systematic review used coaching, delivered by certified physician coaches, to define and reframe perceptions and beliefs around work to align with participant’s values.^49,50 Schneider⁷⁰ developed the framework highlighted in Video 3 (online), which helps to reframe experiences while balancing energy influencers (such as burnout) with perspectives and behaviors that promote performance. Here is an example of using the Schneider⁷⁰ framework in partnership with mindfulness throughout the day: increase awareness when we feel something uncomfortable in our bodies (level 1-2 adrenaline). Accept the feeling rapidly and breathe (level 3) to calm ourselves down. Explore and normalize our feelings (level 4). Regulate these feelings: what we can learn from this experience? (level 5) As leaders, being aware of the influence of internal perceptions and beliefs on our work interactions can have an impact on our colleagues and work environment.

Broader calls to action have highlighted the need for structural changes within healthcare systems to reduce provider burnout.⁷¹ Surgeon-leaders can further reduce burnout by raising awareness and advocating for structural changes within our healthcare organizations. The framework by Thomas et al⁷² emphasizes the importance of commitments at societal, organizational, interpersonal, and individual levels for addressing burnout. Organizational interventions have been found to be superior to individual-based interventions.⁷³ Nevertheless, even modest impacts can have important downstream effects; a 1-point increase in emotional exhaustion on the MBI-EE tool is associated with a 5% increase in medical error,⁹ and a 7% increase in suicidal ideation.⁷⁴ We can be the innovators (the first 2.5%) and the early adopters to reach the tipping point (14%–20%) and create change.⁷³ The role of management is to change the process; we must advocate for change at the organizational level to build supportive systems in the healthcare environment (see Video 3 [online]).

MODULE 4: BUILDING RESILIENCE

Mindfulness techniques are intended to harness one’s self- and situational awareness, building resilience. (See Video 4 [online], which discusses emotional intelligence and its relationship to resilience, referencing the Maddaus⁷⁵ article on the resilience bank account as another useful tool to promote healthy behaviors to reduce physician burnout.) Surgeon Maddaus⁷⁵ coined the term resilience bank account as a metaphoric account for habits that every physician can develop to improve resiliency against burnout and work-life stressors: sleep, exercise, meditation, self-compassion, connection, and gratitude. The last 3 (self-compassion, connection, and gratitude) go hand-in-hand with emotional intelligence. Expanding our emotional intelligence vocabulary can help us identify what we are feeling and experiencing in the moment. In turn, practicing self-compassion and compassion toward others can reduce empathic distress (which is an overidentification with the sufferer that has negative consequences for ourselves). A stronger emotional intelligence vocabulary can improve social skills and connections. This connection with others has never been more important, outlined in the Surgeon General’s 2023 Special Advisory “Our Epidemic of Loneliness and Isolation.” The practice of gratitude, first within us and then by reaching out to others, has a relationship-enhancing quality. Improving our emotional intelligence requires practice and study through tools such as loving-kindness meditation and extending our gratitude toward others, but if it brings us closer to the people in our lives and workplace, reducing loneliness and isolation, that practice will pay in dividends (see Video 4 [online]).

Video 4. This video discusses emotional intelligence and its relationship to resilience, referencing Michael Maddaus’ paper on the Resiliency Bank Account, as another useful tool to promote healthy behaviours to reduce physician burnout.

Download video file ^{(33.4MB, mp4)}

MODULE 5: TRANSLATING MINDFULNESS INTO PRACTICE

Mindfulness interventions have consistently illustrated small but important reductions in burnout and stress among physicians, residents, and medical students. These interventions have been successful regardless of format, duration, and technology. Similar to formal courses, we have presented a short 4-module overview of mindfulness that can be a starting point for each plastic surgeon’s mindfulness toolkit. The next step is to debrief: What resonated with you? Where should we go from here as a physician, a department, or an institution? What practical steps integrate mindfulness into your practice? (See Video 5 [online], which discusses practical steps to integrate mindfulness into your surgical practice.) We hope that this article advances the conversation on burnout and mindfulness among plastic surgeons within your institution and across our specialty (see Video 5 [online]).

Video 5. This video discusses practical steps to integrate mindfulness into your surgical practice.

Download video file ^{(64.7MB, mp4)}

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. We would like to thank the Barnes-Jewish Foundation in St. Louis (MO) for their support of this work (including coverage of publication fees).

ACKNOWLEDGMENT

The authors would like to acknowledge and thank the help of Jackie Phinney for her review of the search strategy.

DECLARATION OF HELSINKI

This article conforms to the guidelines set forth by the Declaration of Helsinki in 1975.

Supplementary Material

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