Larry Beresford

Mindfulness has been studied and supported as an adjuvant therapeutic intervention for a number of chronic medical conditions commonly seen in the primary care setting. The term refers to a quality of awareness that is cultivated through meditation training as a way to pay more careful, non-judgmental attention to the here-and-now. 

Jon Kabat-Zinn, PhD, who introduced mindfulness-based stress reduction in 1971 at the 

Center for Mindfulness in Medicine, Health Care and Society

 at the University of Massachusetts Medical School, describes it in terms of an awareness that arises by paying attention on purpose, in the present moment, in the service of wisdom and compassion.

It has since been offered as a potential intervention for chronic pain, depression, and anxiety, among other conditions. But in addition to helping patients better manage chronic, difficult-to-treat conditions, it could also have benefits for physicians themselves. Practicing mindfulness in their own lives could be a path to managing job stress and burnout.

The term mindfulness could benefit from some demystification, says Michael Krasner, MD, professor of clinical medicine at the University of Rochester, N.Y., School of Medicine and Dentistry. Krasner has 

 mindfulness-based stress reduction to practicing physicians at Rochester for nearly 20 years and has written about the program’s benefits for physician well-being and for patient-centered care in 

“There has been a certain amount of commodification of the term in recent years. What we’re essentially talking about are the important qualities for being a good physician-to be an awake, aware, involved human being,” he explains.

“Most of us as physicians could benefit from a little more awareness, and we can utilize that awareness with our patients who have chronic illnesses to help them develop a better sense of self-awareness and take better care of themselves,” Krasner says. With some education and practice, doctors can cultivate those qualities, which can enhance the quality of their own lives and their own well-being. 

Research data connects physicians’ well-being with the quality of the care they deliver, he says. What’s more, successful applications of mindfulness techniques by patients could increase their satisfaction with their medical care, as expressed in quality and customer satisfaction surveys. This is particularly important with chronic conditions for which there is no easy or permanent fix, for which dissatisfaction rates could be high.

The areas with the strongest evidence for the benefits of mindfulness training for patients include preventing relapse from major depressive disorders, addressing anxiety, especially for patients who don’t want to take medications, and managing chronic pain, which is now a hot-button topic across the health care system. 

 found that mindfulness meditation training reduced clinically measured blood pressure in patients with high-normal BP or grade 1 hypertension. Other research suggests it may have benefits for migraine as part of a stress-reducing lifestyle and as part of therapy for patients with post-traumatic stress disorder. 

“There’s a lot of evidence for these chronic conditions-certainly as much as for pharmaceuticals,” says Anthony Back, MD, co-director of the Center for Excellence in Palliative Care at the University of Washington and cofounder of 

, which teaches clinicians communication skills for use with serious illnesses. 

In the United Kingdom, the National Health Service calls mindfulness-based cognitive therapy a preferred therapy for preventing relapse after recurrent major depressive disorder, and it has been 

 to be as powerful as medications in decreasing incidence of relapse. And a mindfulness-based program focused on chronic pain management has been shown to improve pain patients’ quality of life, Krasner says. “Their actual pain scores didn’t change, but they were better able to adapt to the pain.”

But if physicians are going to suggest mindfulness training to their patients as a way of better managing certain chronic conditions, Back recommends getting to know first-hand how it really works and meeting the teachers of mindfulness practice in their community. By taking a mindfulness course as an individual, the doctor can get a better sense of how it might be received by patients. Not everyone will be open to a suggestion of pursuing mindfulness training, Back adds. But with the right teacher it can help many patients.

Mindfulness classes are taught today in most communities, although coverage for them in health insurance benefits is variable. The physician’s challenge, he adds, is to understand that mindfulness is not a medical treatment in the traditional sense. Instead, it means starting on a path toward behavioral change, retraining the brain to better deal with challenges such as chronic pain. 

“It’s not that we’re going to eradicate your pain-but we can help you do things that matter in order to live a more functional life,” Back says. “We have conditioned people to think there’s a pill for everything, and so physicians have to explain why chronic conditions like pain need to be managed differently.”

There is a fair amount of evidence that a mindfulness practice can also help physicians proactively avoid job stress-related burnout, Back says. “By itself it may not be a magic bullet. But it’s one of the skills doctors can bring to bear in a stressful work environment.” And in this way, they can restore some balance to their work day and reconnect with what drew them to the profession in the first place.  

Burnout is a chronic disease that is crippling the medical profession, says Gail Gazelle, MD, assistant professor of medicine at Harvard Medical School and a physician coach in job stress management, burnout prevention, leadership, and wellness. “Mindfulness can help with these issues by generating calm, refocusing on what is going well and tuning out distractions,” she says.

A lot of physicians today say they feel like they are imposters, an attitude which can be inculcated by the rigors of medical training, Gazelle says. Mindfulness training encourages doctors to pay attention to the present moment, with less of the self-judgment that is sometimes brought to these interactions. 

The mind is a very busy place, Dr. Gazelle says. “Yet you can learn to quiet your mind. Doctors sometimes say they can’t meditate because their mind is too busy-but in mindfulness training, you’re working with the mind as it is. Meditation helps us repetitively shift our thoughts back to our breath-strengthening that muscle. But it takes training and finding the time to sustain the practice.”

Mindfulness classes teach such techniques as using a meditative anchor, for example, observing one’s breath; adopting an appropriate meditation posture; experiencing routine tasks as if for the first time; and trying to integrate mindfulness into everyday life. When seeing the next patient, the doctor can stop at the doorknob and take a deep breath to be present before entering the room. A number of mindfulness apps are available online, Dr. Gazelle says, such as the 

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In addition to helping patients better manage chronic, difficult-to-treat conditions, mindfulness could help physicians manage job stress and burnout.

What can mindfulness offer to you and your patients?

Managing dementia in older patients can be among the hardest things doctors face in ambulatory care, says Barak Gaster, MD, a primary care physician (PCP) and professor of medicine at the University of Washington in Seattle. 

Incidence is high, especially in patients over 85. An estimated 6 million Americans have Alzheimer’s disease, the most common form of dementia, while another 12 million have mild cognitive impairment. As a result, PCPs are frequently confronted by dementia’s complexities and dilemmas, whether making a clear diagnosis or helping patients and their families adjust to the lifestyle changes it imposes.

“It is an emotionally fraught and time-consuming conversation for the PCP,” Gaster says. “There can be a lot of uncertainty involved, and a lot of fear when you’re talking about the slow progressive loss of what many people would consider as their central identity-their cognition.” Add to that, there aren’t enough dementia experts, neurologists, geriatricians, or geriatric psychiatrists, to collaborate with. So the responsibility for both diagnosing and managing patients with dementia often falls largely on the PCP.

Gaster trains internal medicine residents at UW. “My primary message in teaching about dementia is that we need to try to do a better job. Just go back to bedrock principles of primary care and make a commitment to the patient that you are going to be there for them and help them with whatever they are going to face medically,” he says.

Some patients, family members, and even physicians may be reluctant to acknowledge that dementia could be present, particularly at a time when there is no known cure. But failure to acknowledge the diagnosis can lead to poor care and miss opportunities to make important decisions for what lies ahead. Such decisions might include retiring from driving, completing an advance directive, appointing a trusted proxy for future health care decision making, considering other financial and legal needs, and incorporating memory aids and other tools.

“Perhaps the most important action for the PCP to take is to bring family members into the treatment planning process,” he adds. “Traditionally, patients come to PCP visits by themselves, but if they have gradually worsening dementia, it’s important to make sure family members are at the appointments. That way everybody hears the same thing from the doctor, and they can get involved in making good, caring decisions,” he says.

“One of the worst outcomes is stumbling into later stages of dementia without a diagnosis or family intervention. Families get angry because they don’t understand what’s happening to their loved ones or why they are forgetting things.” 

Mary Ann Forciea, MD, an internist and geriatric specialist at the University of Pennsylvania, says the slow, gradual progression of dementia, with subtle changes in the early stages, is another challenge for the PCP. She recommends using Medicare’s annual wellness visit to screen for cognitive impairments. 

, a screening tool for identifying cognitive impairments in older adults, takes only three or four minutes to administer. “If I suspect something is going on, a slightly longer screening tool is the 

,” Forciea says. Even the longer screening can be done in a doctor’s office. “But the problem for the doctor is time. This is a detection exercise, listening for subtle differences, trying to hear symptoms that are odd or new or different.”

John Cullen, MD, president-elect of the American Association of Family Practice and a family practice physician at Valdez Medical Clinic, Valdez, Alaska, agrees that dementia can be one of the most challenging aspects of his job. It can be hard to distinguish dementia from other causes of cognitive loss, such as metabolic hypothyroidism or depression, which might be treatable.

“Mostly I see patients’ anxieties. I think most people (with dementia) have an inkling that something is wrong. If you don’t bring it up, they’re thinking about it anyway,” he says. Cullen tells his patients that the current Alzheimer’s treatments are not terribly effective, although they can try them if they wish. “At that point, we’re focusing more on the structures in their lives that will allow them to stay at home. The goal is to keep the patient at home for as long as possible.”

Forciea recommends encouraging patients to complete an advance directive, outlining their values and preferences for future medical care, while they are still able to participate. The PCP can advise the family to get an estate lawyer for financial planning and asset protections. Knowing that a plan is in place can offer some peace of mind.

In later stages, many patients can still remain in the home with the support of family caregivers, paid caregivers, neighbors, members of their religious community, and/or other support networks-although this may require significant coordination. Hospice care also plays a growing role in maintaining the dignity of patients with advanced dementia, Forciea says.

“Communicating about a dementia diagnosis in its early stages allows the doctor to impart a key message: This is not a death sentence,” Gaster concludes. “The disease can progress very slowly. People can stay themselves for many years, and they don’t need to be defined by their dementia. Living with memory loss is not easy, but there are ways to cope, to keep routines, to get exercise, to keep cognitive function longer and still find ways to enjoy life,” he adds. 

“The PCP in many ways is well suited to take on this challenge. Primary care is the ideal model of a trust-building relationship.”

Other dementia management suggestions for PCPs

Don’t dismiss memory concerns as “normal aging” without doing a proper assessment;

Alzheimer’s Association’s new workgroup recommendations

 on improving timely and accurate diagnosis and disclosure of dementia, reported at the Alzheimer’s Association International Conference in Chicago in July, with 20 recommendations for physicians and other professionals;

Employ the practice’s social worker, if there is one, to address families’ concerns and connect them with resources; or else refer them to the local Area Agency on Aging;

Reconsider medications that can worsen memory or thinking in de­mentia patients, such as Ambien or Oxybutynin;

Investigate Gaster’s advance directive document 

, which addresses patients’ values and preferences at different stages of the disease. He recommends sharing this tool with every patient who turns 65 at their annual wellness visit-even before a diagnosis of dementia has been made.

The responsibility for both diagnosing and managing patients with dementia often falls largely on the primary care physician.

Managing dementia in the ambulatory care setting 

	Do most physicians know what treatments their patients would want if they became seriously or even terminally ill?

	Since 2016, physicians have been able to bill Medicare’s Physician Fee Schedule for a visit with a beneficiary to discuss advance care planning and preferences about the patient’s medical care for some future point when the patient’s condition worsens or the person is no longer able to express care preferences. 

	This care planning conversation might make some patients-and physicians-uncomfortable, but it is voluntary and it offers an opportunity to explore the patient’s values and wishes in a circumstance when no crisis is looming.

	“We are quickly moving to a healthcare payment system based on value and outcome,” says Jean Acevedo, a healthcare billing and compliance consultant in Delray Beach, Florida. “Any service that can help patients make personal decisions about their healthcare, based on how much aggressive treatment they are likely to want or not want in those situations, is a good thing.”

	Not only that, she says, but Medicare encourages physicians to do an annual wellness visit with their Medicare patients-even sending emails to beneficiaries reminding them of this service. If at that wellness encounter a discussion about advance care planning is initiated, there is no co-pay for the patient, but the physician is able to charge an additional fee for the advance care planning part of the visit.

	Advance directives are written legal documents designed to allow patients to guide their medical care at a future time when they can no longer speak for themselves. One type of advance directive, the living will, describes medical treatments a person might want or not want, while the Durable Power of Attorney for Health Care Decisions names a surrogate authorized to speak on the patient’s behalf. 

	In a number of states, a related document called POLST (Physician Orders for Life-Sustaining Treatment) allows patients and their physicians to spell out more specific treatment choices when the patient’s advancing illness makes them timelier.

	In all of these cases, the advance directive document should follow a thoughtful conversation. 

	The patient’s attending or primary care physician often is best situated to guide such conversations, based on a history with the patient and an understanding of the kinds of medical issues that are likely to shape the patient’s future medical needs.

	Those future needs are far from self-evident, but the physician can help the patient understand what is reasonable to expect. While advance directive documents are often associated with a preference to withhold aggressive treatments such as resuscitation, mechanical ventilation or feeding tubes, they can also be used to capture preferences for everything medically appropriate to be done in a crisis.

	The legal framework for advance directives varies considerably from state to state, but a number of national groups, including Five Wishes, the Conversation Project, and many health plans, try to make it easier for patients to access sample documents and tools for completing them. Other groups are developing electronic registries to make the patient’s advance directive more easily accessible in a crisis.

	“Everyone would agree: these conversations are very important, and for the government to pay for them is a huge step forward,” says Tim Short, MD, a palliative care physician at the University of Virginia Health System in Charlottesville. “But it’s not enough to pay for them; we need to make sure that practitioners know what they’re doing-which may require training.”

	Short says these conversations are happening more often these days but they don’t always translate in meaningful ways to impact how care is delivered.

	“I live and breathe these conversations every day in my work, so I was surprised to find that we don’t have really good double-blind data on the outcomes and effectiveness of advance care planning.”

	The fee for a doctor’s care planning visit, based on time spent, can run about $85 for an encounter lasting between 16 and 30 minutes. The government doesn’t spell out additional requirements for the visit, Acevedo says.

	“Medicare is pretty clear that this is a voluntary discussion for the patient, the documentation should reflect that the patient consented to have the discussion,” she says. 

	The notes should address who was present and what kinds of treatment decisions were made or advance directive documents discussed. “And, of course, since these are time-based codes, the number of minutes spent in the discussion must be documented,” Acevedo adds. But it is not required that a completed advance directive results from the visit. 

	Advance care planning, done to help prevent the provision of care that would not be wanted by the patient, requires a discussion with that patient, says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine and a physician in Louisville, Kentucky. 

	“The people we care for want to have a say in their care. Many families have had the experience of a loved one who was on life support, where the family has to make painful decisions. The only thing that can make it easier is if they know what the patient would have wanted,” he says.

	“I don’t believe doctors want to give futile, harmful care to their patients, but the default position in our medical culture is to do everything,” Rotella adds. “We all find it challenging to talk about the end of life. But when we lean in and think about it and take some control over our preferences and have these conversations, we realize that we do have choices. It can be empowering.” 

Physicians must confront these difficult conversations 

Why end-of-life care planning is a necessary service

	Do you know what treatments your patients would want i

f they became seriously or even terminally ill?

	Since 2016, physicians have been able to bill Medicare’s Physician Fee Schedule for a visit with a beneficiary to discuss 

and preferences about the patient’s medical care for some future point when the patient’s condition worsens or the person is no longer able to express care preferences. This care planning conversation might make some patients-and physicians-uncomfortable, but it is voluntary and it offers an opportunity to explore the patient’s values and wishes in a circumstance when no crisis is looming.

 Bundled pricing is the only true transparency in healthcare

Legal Documents-and the Conversations that Guide Them 

	Advance directives are written legal documents designed to allow patients to guide their medical care at a future time when they can no longer speak for themselves. One type of advance directive, the living will, describes medical treatments a person might want or not want, while the Durable Power of Attorney for Health Care Decisions names a surrogate authorized to speak on the patient’s behalf. In a number of states, a related document called POLST (Physician Orders for Life-Sustaining Treatment) allows patients and their physicians to spell out more specific treatment choices when the patient’s advancing illness makes them timelier.

	In all of these cases, the advance directive document should follow a thoughtful conversation, also called advance care planning, an ongoing process of clarifying and defining one’s values and preferences for a variety of future scenarios. The patient’s attending or primary care physician often is best situated to guide such conversations, based on a history with the patient and an understanding of the kinds of medical issues that are likely to shape the patient’s future medical needs.

Next: Coversations don't always translate well

	The legal framework for advance directives varies considerably from state to state, but a number of national groups, including 

, and many health plans, try to make it easier for patients to access sample documents and tools for completing them. Other groups are developing electronic registries to make the patient’s advance directive more easily accessible in a crisis.

	“Everyone would agree: these conversations are very important, and for the government to pay for them is a huge step forward,” says Tim Short, MD, a palliative care physician at the University of Virginia Health System in Charlottesville. “But it’s not enough to pay for them; we need to make sure that practitioners know what they’re doing-which may require training.  There’s a risk that the process could just become boxes to check, while a different approach is needed for different people at different stages of life.

It's about time PCPs say enough is enough

	“We are having more of these conversations these days, but they don’t always translate in meaningful ways to impact how care is delivered or to patients getting the care they say they want,” Short adds. “I live and breathe these conversations every day in my work, so I was surprised to find that we don’t have really good double-blind data on the outcomes and effectiveness of advance care planning. But in the end, it doesn’t change my commitment or passion for talking about care preferences with my patients. I can’t tell you how many times I’ve sat in the waiting room of a trauma unit with a family that has never thought about these things.”

	The fee for a doctor’s care planning visit, based on time spent, can run about $85 for an encounter lasting between 16 and 30 minutes. The government doesn’t spell out a lot of additional requirements for the visit, Acevedo says.

	“But since Medicare is pretty clear that this is a voluntary discussion for the patient, the documentation should reflect that the patient consented to have the discussion,” she says. The notes should address who was present and what kinds of treatment decisions were made or advance directive documents discussed. “And, of course, since these are time-based codes, the number of minutes spent in the discussion must be documented,” Acevedo adds. But it is not required that a completed advance directive results from the visit.

	These visits can be provided in a variety of settings, including the hospital and the clinic, but must be made in person-with the patient or with a family member or surrogate-using billing codes 99497 for the first 30 minutes and 99498 for additional minutes. There are no limits on how often these visits can be repeated, although it would be good to document changes in the patient’s health status, Acevedo says. Anyone who is able to independently bill Medicare for a medical visit, including advanced practice professionals, can bill for this visit, as well, and the physician can also assign some of the conversation to office staff “incident to” the initial encounter.

	Advance care planning, done to help prevent the provision of care that would not be wanted by the patient, requires a discussion with that patient, says Joseph Rotella, MD, chief medical officer of the American Academy of Hospice and Palliative Medicine and a physician in Louisville, Kentucky. “The public and the people we care for want to have a say in their care. Many families have had the experience of a loved one who was on life support, where the family has to make painful decisions. The only thing that can make it easier is if they know what the patient would have wanted,” he says.

	“This is an agonizing position for families to be in, and some of us want to make it easier for the patient and family,” Rotella says. “Frankly, if I imagine myself in that position, totally sedated, I’m not as concerned about what happens to me as about what my family is going through. That’s the same reason people make wills, to ensure that they don’t put their family in a tougher situation than it needs to be.”

Warning signs to look for to avoid practice embezzlement

	“I don’t believe doctors want to give futile, harmful care to their patients, but the default position in our medical culture is to do everything,” Rotella says. “

We all find it challenging to talk about the end of life

. But when we lean in and think about it and take some control over our preferences and have these conversations, we realize that we do have choices. It can be empowering.”

Do you know what treatments your patients would want if they became seriously or even terminally ill?

Author | Larry Beresford

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What can mindfulness offer to you and your patients?

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Why end-of-life care planning is a necessary service

Is end-of-life planning truly necessary?