Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial

Abstract

Importance: Mindfulness meditation training has been shown to be feasible in surgical trainees, but affective, cognitive, and performance benefits seen in other high-stress populations have yet to be evaluated.

Objective: To explore potential benefits to stress, cognition, and performance in postgraduate year 1 (PGY-1) surgery residents receiving modified mindfulness-based stress reduction (modMBSR).

Design, setting, and participants: This follow-up study is an analysis of the Mindful Surgeon pilot randomized clinical trial of modMBSR (n = 12) vs an active control (n = 9), evaluated at baseline (T1), postintervention (T2), and 1 year (T3), took place at an academic medical center residency training program among PGY-1 surgery residents. Data were collected between June 2016 and June 2017 and analyzed from June 2017 to December 2017.

Interventions: Weekly 2-hour modMBSR classes and 20 minutes of daily home practice during an 8-week period vs an active control (different content, same structure).

Main outcomes and measures: Preliminary evidence of efficacy was explored, primarily focusing on perceived stress and executive function and secondarily on burnout, depression, motor skill performance, and changes in blood oxygen level-dependent functional neuroimaging during an emotion regulation task. Group mean scores were calculated at T1, T2, and T3 and in linear mixed-effects multivariate analysis. Effect size for analysis of covariance is presented as partial η2 with the following cutoff points: small, less than 0.06; medium, 0.06 to 0.14; large, greater than 0.14.

Results: Postgraduate year 1 surgery residents (N = 21; 8 [38%] women) were randomized to a modMBSR arm (n = 12) or an active control arm (n = 9). Linear mixed-effects modeling revealed differences at T2 and T3 in perceived stress (mean [SD] difference at T2: modMBSR, 1.42 [5.74]; control, 3.44 [6.71]; η2 = 0.07; mean [SD] difference at T3: modMBSR, 1.00 [4.18]; control, 1.33 [4.69]; η2 = 0.09) and in mindfulness (mean [SD] difference at T2: modMBSR, 3.08 [3.63]; control, 1.56 [4.28]; η2 = 0.13; mean [SD] difference at T3: modMBSR, 2.17 [3.66]; control, -0.11 [6.19]; η2 = 0.15). Burnout at T2 (mean [SD] difference: modMBSR, 4.50 [9.08]; control, 3.44 [6.71]; η2 = 0.01) and T3 (mean [SD] difference: modMBSR, 5.50 [9.96]; control, 5.56 [9.69]; η2 = 0.01) showed similar increase in both groups. Working memory increased more at T2 in the modMBSR arm (mean [SD] difference, 0.35 [0.60]) than in the control arm (mean [SD] difference, 0.21 [0.74]; η2 = 0.02) and at T3 (modMBSR, 0.68 [0.69]; control, 0.26 [0.58]; η2 = 0.20). Cognitive control decreased more in the control arm at T2 (mean [SD] difference at T2: modMBSR, 0.15 [0.40]; control, -0.07 [0.32]; η2 = 0.13) and at T3 (mean [SD] difference: modMBSR, 0.07 [0.59]; control, -0.26 [0.53]; η2 = 0.16). Mean (SD) circle-cutting time improved more at T2 in the modMBSR arm (-24.08 [63.00] seconds) than in the control arm (-4.22 [112.94] seconds; η2 = 0.23) and at T3 in the modMBSR arm (-4.83 [77.94] seconds) than in the control arm (11.67 [145.17] seconds; η2 = 0.13). Blood oxygen level-dependent functional neuroimaging during an emotional regulation task showed unique postintervention activity in the modMBSR arm in areas associated with executive function control (dorsolateral prefrontal cortex) and self-awareness (precuneus).

Conclusions and relevance: In this pilot randomized clinical trial, modMBSR in PGY-1 surgery residents showed potential benefits to well-being and executive function, suggesting a powerful role for mindfulness-based cognitive training to support resident well-being and performance, as mandated by the Accreditation Council for Graduate Medical Education.

Trial registration: ClinicalTrials.gov identifier: NCT03141190.

Figure 1.. CONSORT Flow Diagram

^aTwo participants were enrolled but were withdrawn by their parent program before completing assessment battery or attending any study sessions owing to conflicts with specialty-specific didactic sessions and concern for compromised education. ^bOne participant was initially allocated to the active control but did not receive the intervention owing to inadvertently attending the modMBSR training class during week 1. She was therefore reassigned to the modMBSR intervention group. ^cTwo participants did not have functional magnetic resonance imaging (fMRI) scans analyzed. One was never scanned owing to implanted metal, and the other was scanned but data were incomplete (protocol glitch) and could not be analyzed.

Figure 2.. Working Conceptual Model and Associated Outcome Measures

aMBI indicates abbreviated Maslach Burnout Inventory; CAMS-R, Cognitive Affective Mindfulness Scale–Revised; fMRI, functional magnetic resonance imaging; NIH-EXAMINER, National Institutes of Health Executive Abilities: Measures and Instruments for Neurobehavioral Evaluation and Research; PHQ, Patient Health Questionnaire; PSS, Perceived Stress Scale.

Figure 3.. Functional Brain Scan Activation During Emotional Regulation Task

A, Patterns of activation unique to viewing negative images in the intervention and control groups at baseline. Right panel shows activation of inferior occipital gyrus (IOG), which is associated with the processing of emotionally salient images. B, Patterns of activation unique to the action of decreasing emotional response to negative images (ie, reappraisal) in the intervention and control groups at baseline. Right panel shows activation of ventrolateral prefrontal cortex (vlPFC), which includes the inferior frontal gyrus (IFG) and is associated with the reinterpretation of affective stimuli to alter the emotional impact. C, Patterns of activation unique to the action of decreasing emotional response to negative images, only seen in the intervention group and only seen after the intervention. Lower panel shows activation of dorsolateral prefrontal cortex (dlPFC), which includes the middle frontal gyrus (MFG) and superior frontal gyrus (SFG) and is associated with the functioning of the executive control hub of higher-order cognition. The precuneus (precun), which is anatomically within the posterior cingulate cortex (PCC), is associated with mental imagery, visuospatial motor skills, and self-awareness. Both areas showed activation in the modified mindfulness-based stress reduction arm postintervention. D, Schematic diagram of the timing and steps involved in the presentation of each image for the emotional regulation task. BOLD indicates blood oxygen level–dependent; fMRI, functional magnetic resonance imaging; L, left; and R, right.