Photo: Vanessa MacCormick.
Photo: Vanessa MacCormick.

Course teaches mindfulness to students

WCVM professor Dr. Trish Dowling talks about Mindful Veterinary Practice, her popular elective course that's offered to third-year veterinary students.

It's near the end of another busy day at the Western College of Veterinary Medicine (WCVM). If you are walking by the Alberta Room on the third floor and look in, you may see the tables, couches and chairs pushed back to the walls and 20 veterinary students are sitting silently or lying motionless on the carpeted floor.

This can go on for anywhere from 10 to 45 minutes at a stretch. This looks a little crazy and you might wonder why the vet students aren't doing anything.

Actually, they are very hard at work practicing non-doing. They are actively turning in to the present moment, training to focus their attention and awareness from one moment to the next. They are practicing mindfulness. These third-year students are taking my Mindful Veterinary Practice (MVP) elective.

Mindfulness in medicine: patients and practitioners

". . . the faculty of bringing back a wandering attention, over and over again, is the root of judgment, character and will. No one is compos sui (master of one's self) if he have it not. An education which should improve this faculty would be the education par excellence. But it is easier to define this ideal than to give practical directions to bring it about."
                                                                                                      — William James —

William James wrote these words in his 1890 textbook: The Principles of Psychology. Ninety years later, Jon Kabat-Zinn solved James' dilemma by developing the Mindfulness Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center. Kabat-Zinn initiated the program as a practical way to train attention and facilitate life balance and self-care in both patients and health care professionals.1

The practice of "mindfulness" means paying attention on purpose, in the present moment, nonjudgmentally. Mindfulness practices activate neural circuits in the left prefrontal cortex, lowering reactivity to challenging experiences. They increase the ability to notice, observe, and experience bodily sensations, thoughts, and feelings even though they may be unpleasant.

They also strengthen the ability to act with awareness and attention, in contrast to being on "autopilot." The documented benefits of mindfulness training for health care students and professionals include reduced psychological distress, increased empathy, increased working memory capacity and attention, improved patient care and reduced medical errors.2

More than 100 North American medical schools integrate various forms of MBSR programs into their curricula and continuing education programs. The MVP elective is the first MBSR program in a veterinary college curriculum.


Stress in veterinary medicine

"We must face up to the fact that our medical training programs hurt people."
                                                                                                    — M. S. Krasner, MD —

Similar to a medical curriculum, the veterinary medical curriculum is a rigorous academic program whose heavy workload and intense time demands cause significant stress in students.

Stressors in the clinical years and in veterinary practice include long work hours, lack of control over workload, emergencies, unexpected deaths, euthanasia, client grief, compassion fatigue, treatment failure, surgical challenges, difficult clients, interpersonal conflicts and medical errors.

These stressors put both veterinary students and practitioners at high risk for mental, physical and emotional fatigue and for substance abuse.3,4 These negative affects appear to significantly increase the risk of suicide by veterinarians.5 Our overall rate of suicide is approximate four times that of the general population and twice that of medical doctors and dentists.

There is a gender effect, as female veterinarians are more than seven times more likely to die from suicide than individuals in the general population. Although successful and resilient veterinary students and veterinarians set realistic expectations and cultivate positive psychological coping mechanisms on their own that enable them to succeed both in school and in their careers, veterinary medical education itself has tended to ignore training in self-care skills.

The 2003 University of Saskatchewan's Student Health Centre needs assessment reported that 75.4 per cent of third-year veterinary students in the sample surveyed rated themselves "highly to overwhelmed by stress," while only 35 per cent of students from other colleges categorized themselves as having this level of stress (Unpublished data, Herman et al., 2003).

These findings prompted the 2008 study, "Student Stress in Veterinary Medicine: Examining the College's Role," conducted by Student Counselling Services, which further documented problematic stress levels among veterinary students (Unpublished data, Herman et al., 2008). Their report concluded with a recommendation that the WCVM offer students ways to increase their range of coping skills.

Across North America, veterinary schools have begun making changes in their programs to develop and strengthen emotional competencies and coping skills of their students. However, there is still little indication that these program changes are being adequately assessed.

Timmins6 makes a plea for outcome assessment: "There is a significant risk in imposing new programs on students without careful attention to gathering data that will inform the profession about the effectiveness of these activities. The concern is not just the possible waste of resources but also the potential to frustrate and alienate future practitioners if errant programs do not deliver on their promises. It is reasonable for veterinary educators to apply the same critical analysis of new techniques for teaching emotional competencies that they apply to the teaching of new orthopedic procedures or therapeutic protocols."

As part of the revised WCVM curriculum in 2010, a variety of elective courses began to be offered in the third year. This opportunity sparked the development of the Mindful Veterinary Practice (MVP) elective, and I obtained funding from the Gwenna Moss Centre for Teaching Effectiveness (GMCTE) to assess the effects of MVP on specific aspects of students' attentional functioning and self-reported mindfulness.

The Mindful Veterinary Practice elective

Show up.

Pay attention.

Tell the truth, without judgment or blame.

Don't be attached to outcome.
— Angeles Arrien, The Four-Fold Way


The MVP elective draws on the curriculum of a Mindfulness Based Stress Reduction (MBSR) program. It is customized for veterinary students by including components of the Mindful Practice program, a series of modules presented to third-year medical students and residents, developed by faculty of the University of Rochester Medical School.

Before signing up for the elective, students must commit themselves to attending a 90-minute class twice weekly and to doing 45 minutes of homework each day.

Since this course is unlike any other course in their curriculum, they are frequently unsure about it. When students ask, "What is the goal of this? I mean, what is it that we are striving for?" my answer is to just "do it" for seven weeks and then judge whether or not the mindfulness training was useful.

Students are given a course manual and each session includes a short, didactic presentation and supporting references on that week's theme. Topics include:

  1. Stress and its effects in veterinary students and practicing veterinarians
  2. Psychological and neurophysiological mechanisms of mindfulness
  3. Awareness of thoughts and feelings, perceptual biases and filters
  4. Dealing with pleasant and unpleasant events
  5. Managing conflict
  6. Preventing burnout
  7. Reflecting on meaningful experiences in practice
  8. Setting boundaries
  9. Exploring self-care
  10. Being with suffering.


"When you are thirsty, you don't read a book about drinking."
— Jean-Pierre de Caussade —


The themes provide the rationale for the experiential exercises that take up most of the class time. The goal of mindfulness training is to strike a balance between a vigilant and relaxed state of mind, teaching students to notice subtle distractions (thoughts, feelings, emotions, bodily sensations) while repeatedly bringing attention back to an object of focus (the breath).

With my guidance, students practice four methods of intrapersonal self-awareness:
  1. The body scan: systematically noticing bodily sensations and the cognitive and emotional reactions to the sensations without attempting to change the sensations themselves
  2. Sitting meditation: bringing nonjudgmental awareness to the thoughts, feelings, and sensations experienced
  3. Walking meditation: slow, deliberate, and attentive walking while bringing awareness to the experience
  4. Mindful movement: simple hatha yoga exercises to slowly and methodically explore the sensory, emotional, and cognitive aspects of the body in motion.

In between exercises, the group discusses the effects of the mindfulness practices on various aspects of their lives, including management of pain or injury, eating, sleeping, personal relationships and conflicts, and time and information technology management. In addition to the 45 minutes of daily formal practice, students are also asked to try a variety of informal practices during their daily routines, such as mindful eating.

"…a human mind is a wandering mind, and a wandering mind is an unhappy mind. The ability to think about what is not happening is a cognitive achievement that comes at an emotional cost."
                                                                                                      — M.A. Killingsworth —

Initially, the veterinary students are quite concerned with "getting it right" and about having a "good" meditation as compared to a "bad" one. These highly competitive, high scholastic achievers quickly realize that keeping their attention focused on their breath is not so easy, and that the mind has a life of its own.

Like a Golden Retriever puppy that one is training to sit, the mind easily gets distracted and wanders off. Mindfulness is that moment of recognition that the mind has wandered; and like training a puppy, the instruction is to kindly and firmly bring it back to the focus of attention. Over and over again.

Veterinary students find it difficult to just be present to how it is in the moment without wanting things to be different. As they learn to attend to the present moment, they realize how much mental time they are spending "rehearsing and rehashing" their lives.

Their most difficult practice is invariably mindful eating; these young people don't know how to just eat. They eat and read email, eat and talk, eat and text, eat and watch television. Mindful eating practice evokes awareness of how food really tastes and smells, how they can notice a feeling of fullness before overeating, and what it is that they really like or dislike about a particular food.


Assessing the effects of mindfulness training

To document the effects of mindfulness training in veterinary students, I collaborated with Amishi Jha, PhD, a psychologist and attention researcher at the University of Miami.

I met Dr Jha at the 2009 UMass Mindfulness Research Conference, where she presented the benefits of mindfulness training on attention and working memory capacity in a group more conservative and even more affected by stress than veterinarians: a unit of United States Marines about to deploy to Iraq.7

If Amishi could take on the US Marine Corps, I knew I could find the courage to introduce this program to the veterinary profession. With the support of the WCVM's new dean, Dr Doug Freeman, and Dr. Bruce Grahn, the WCVM's associate dean, academic, I developed and gained approval for the elective course.

With the GMTCE funding, Amishi's laboratory was able to assess the students. Students who took the MVP elective were compared to a control group of their classmates who did not. Participants completed testing before the start of the elective and at the end of the elective through the Jha Lab Online Testing Center.

Participants were given versions of the Attention Network Test8, Five Facet Mindfulness Questionnaire9 and Ruminative Responses Scale10 adapted for online administration. After participating in the MVP elective, veterinary students showed significantly improved self-reported trait mindfulness, as well as reduced rumination and enhanced attentional functioning.

Our findings suggest that the physical and mental awareness practices in MVP improve students' control in processing self-referential thought and conscious detection of mind wandering. Such increased control improves attention. Mindfulness practice by veterinary students, as for other health care professionals, improves mood which also improves cognitive function.

Ongoing Mindful Veterinary Practice

The MVP elective is now in its third year. With the 20-student limit based on the size of the Alberta Room, the course fills rapidly.

In the college, some of the reactions to the MVP class were initially negative: "What do you mean, they are teaching yoga in veterinary school?!" I supply healthy snacks and juice boxes to help students keep their energy up at the end of the day, which resulted in the course being referred to as "Dowling's Little Cult."

Nevertheless, the explosion of documented benefits of mindfulness practices in the scientific literature and the positive feedback from the elective participants has changed negative initial impressions of MVP.

Former participants report back about mindful walking between examination rooms, taking a breath and being fully present to an interaction with a patient and client, and being better able to direct attention broadly (scan the entire treatment room to notice any animal in distress) or precisely (put in the catheter without being distracted by someone doing the chest compressions).

Quantitatively and qualitatively, Mindful Veterinary Practice demonstrates the significant potential of mindfulness training for improving the emotional and cognitive abilities of veterinary students and for providing some protection from stress and burnout in a very demanding profession.

Dr. Trish Dowling is a professor of veterinary clinical pharmacology at the Western College of Veterinary Medicine. Reposted with permission from Bridges, newsletter for the University of Saskatchewan's Gwenna Moss Centre for Teaching Effectiveness. Visit www.usask.ca/gmcte for more information.

References

1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness New York: Dell Publishing, 1990.

2. Irving JA, Dobkin PL, Park J. Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness-based stress reduction (MBSR). Complement Ther Clin Pract 2009;15:61-66.

3. Hatch PH, Winefield HR, Christie BA, et al. Workplace stress, mental health, and burnout of veterinarians in Australia. Aust Vet J 2011;89:460-468.

4. Pickles KJ, Rhind SM, Miller R, et al. Potential barriers to veterinary student access to counselling and other support systems: perceptions of staff and students at a UK veterinary school. Vet Rec 2012;170:124.

5. Bartram DJ, Baldwin DS. Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Vet Rec 2010;166:388-397.

6. Timmins RP. How Does Emotional Intelligence Fit into the Paradigm of Veterinary Medical Education? J Vet Med Educ 2006;33:71-75.

7. Jha AP, Stanley EA, Kiyonaga A, et al. Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion 2010;10:54-64.

8. Fan J, McCandliss BD, Sommer T, et al. Testing the efficiency and independence of attentional networks. J Cogn Neurosci 2002;14:340-347.

9. Baer RA, Smith GT, Hopkins J, et al. Using self-report assessment methods to explore facets of mindfulness. Assessment 2006;13:27-45.

10. Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: the 1989 Loma Prieta Earthquake. J Pers Soc Psychol 1991;61:115-121.
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