MINdI: Mindfulness Instruction for New Interns
By the end of this activity, learners will be able to: 1. Define mindfulness. 2. Explain the relationship between mindfulness and burnout. 3. Demonstrate an awareness of the evidence supporting mindfulness. 4. Report a more positive attitude toward mindfulness. 5. Employ mindfulness techniques more often in their daily lives. 

Burnout is the triad of emotional exhaustion, depersonalization, and feelings of inefficacy. It has been associated with higher rates of provider depression, lower provider empathy, higher rates of perceived medical errors, poorer patient compliance with medical treatment plans, and high provider attrition from the medical profession. – In contrast, mindfulness is the quality of being nonjudgmental and present in the moment. Mindfulness has been shown to reduce provider burnout and increase provider empathy. – Rates of burnout are increasing disproportionately among health care providers compared with other professions, representing a risk to the integrity of the medical workforce. , Pediatric trainees are at equivalently heightened risk, with high rates of burnout at the start of their internships that increase rapidly. Recent literature suggests that rates of burnout in the pediatric trainee population are greater than 50% in each year of training and, not surprisingly, that burnout is associated with stress and sleepiness specifically, both of which may be affected by mindfulness practice. For this reason, the American Association of Pediatrics aligned with the Accreditation Council for Graduate Medical Education in a 2014 statement that emphasized the need for systems-level change to address trainee burnout. Mindfulness was the only evidence-based approach included in the statement that has been shown to reduce trainee burnout. However, competing educational priorities and a perceived need for topic expertise represent barriers to implementing mindfulness education. Within this context, we undertook a needs assessment at our pediatric residency program, which confirmed growing rates of burnout and a desire for related formal curricula. Given the evidence supporting mindfulness, we sought a curriculum that would help our residents (1) better understand the rationale behind, (2) think positively about, and (3) consistently practice beneficial mindfulness techniques with the ultimate goal of ameliorating burnout. Our literature search yielded a growing but still limited body of GME work describing the effects of mindfulness curricula, with one recent review identifying only three total in-person mindfulness interventions with resident participants, none of which shared detailed curricula. – Previously published MedEdPORTAL curricula have focused on different audiences (i.e., medical students) or on wellness and resilience more broadly , ; some consist of only a single session or shorter-term interventions. , Among published resources, all lacked an educational framework supporting the longitudinal, integrated practice of mindfulness techniques in the everyday lives of busy residents that we felt would be critical for sustained behavioral change for trainees. Given this gap, we used Kern's six-step approach to guide the development, implementation, and assessment of a longitudinal mindfulness curriculum: Mindfulness Instruction for New Interns (MINdI). We utilized the conceptual framework of a spiral curriculum and Knowles schema of adult learners to build a curriculum that begins with a session focused on the rationale for mindfulness as a burnout-prevention tool and a curricular model in which each session builds on prior lessons. , We chose to target pediatric interns, a population at the beginning of graduate medical training with much to gain from preventative antiburnout strategies. Our needs assessment led us to maximize applicability for trainees by addressing certain specific areas of the workplace that could increase burnout, such as distractions, conflicting responsibilities, and poor communication. As a result of these considerations, we created an easy-to-implement, facilitator-friendly, and low-cost educational mindfulness innovation, which we evaluated at our own institution among a cohort of pediatric interns to demonstrate feasibility, acceptability, and learner outcomes. 

Our needs assessment survey was conducted among all trainees enrolled in our large, pediatric residency program in September 2015. Of the 137 residents who responded, 83% were open to a curriculum aimed at preventing burnout within their residency training. Given the documented benefits of mindfulness in relation to burnout, we developed, implemented, and evaluated our pilot mindfulness curriculum during the winter of 2015 using postintervention surveys measuring residents' knowledge, attitudes, and behaviors related to the curriculum. Based on feedback from this pilot, we made iterative improvements resulting in the current curriculum, which was continued based on positive feedback and the decision by residency leadership to allocate coveted noon conference didactic time to MINdI for the 2018 and 2019 academic years. MINdI targeted interns, who, in their daily lives, face multiple evolving stressors and destabilizing forces as they transition into an often-vulnerable new role as independent physicians. Sessions were delivered successfully to small and large groups of anywhere from six to 30 interns at a time; facilitators reviewed the space and materials needed to conduct sessions for larger groups ahead of time via the MINdI Facilitator Guide  and Session Materials Guide . The sessions were written so that anyone could facilitate, even those without prior mindfulness experience. Chief residents, supervising residents, faculty, and hospital administrators have all successfully facilitated this curriculum. MINdI included one 30-minute and six 1-hour lunchtime sessions . The first session was ideally delivered prior to the start of clinical work during intern orientation, with six additional sessions delivered over the subsequent 6 months (approximately one session per month). However, this time line was flexible and was sometimes adapted based on preexisting protected time within our individual residency's didactic schedule. The first session utilized a 30-minute PowerPoint presentation  to review the data defining and outlining the growing risk of burnout among medical professionals and share the scientific rationale and evidence for implementing mindfulness as a strategy for burnout prevention. With this session, facilitators garnered buy-in for the curriculum overall. Each subsequent session had three components: (1) built-in protected time to eat and socialize, (2) practice of an active mindfulness exercise, and (3) a facilitated reflection about using mindfulness in the workplace. Participation was encouraged but always voluntary. Anecdotally, the most common reasons for nonattendance were either being postcall or competing clinical demands. As per our standard residency policy, supervising residents and fellows were asked to silence phones and pagers, but this was not rigorously enforced. Each exercise had unique materials and audiovisual needs, as outlined in . These ranged from access to a computer with internet, audio, and PowerPoint projection capabilities to more-specific materials such as pens, paper, envelopes, or stress balls. The sessions and corresponding appendices are listed below: • The Science of Burnout and Mindfulness ( : PowerPoint presentation). • Mindfulness and Awareness of the Physical Body ( : facilitator preparation video and : session audio). • Mindfulness and Awareness of the Mind and Thoughts ( : session audio). • Mindfulness and Awareness of the Mundane ( : facilitator preparation audio). • Mindfulness and Awareness of Chaos. • Mindfulness and Awareness of Communication ( : PowerPoint presentation and : facilitator preparation audio). • Mindfulness to Prevent Burnout ( : session audio). • Optional: 10-Minute Mindfulness Refresher ( : session audio). Some sessions required participants to have space to spread out or walk around the room while others were predominantly delivered with participants seated at tables. Our experience with the curriculum clarified that it was important for participants to feel comfortable and safe within the physical space during each session. The most successful sessions were delivered in a closed room dedicated to implementing the mindfulness session where nonparticipants (such as other residents or staff) were absent and pagers and phones were silenced. An anonymous paper survey assessing baseline demographic and mindfulness experience and practice data was administered prior to the first MINdI session. We distributed a postcurriculum paper survey consisting of multiple-choice questions designed to measure impact on our stated objectives immediately after the completion of the final MINdI session 6 months later. To develop these surveys, initial drafts were piloted among a group of senior and chief residents and then modified based on feedback related to clarity and question content. We collected qualitative data at the conclusion of each session using a two-question plus/delta activity to elicit feedback regarding what worked well (i.e., plus) and what could be improved (i.e., delta). Two research team members independently coded responses and then jointly reviewed and combined codes into a final codebook, reaching consensus through discussion about disagreements. , A third team member reviewed a randomly generated sample of 20% of the plus and delta codes for external validation. Codes were then iteratively organized into categories and themes. Institutional review boards at both institutions affiliated with the Boston Combined Residency Program deemed this study exempt. 

Fifty interns consented to participate in the study. All 50 interns completed the baseline demographic survey (100% response), and 84% (42 out of 50) completed the postcurriculum survey 6 months later. Quantitative Results At baseline, 50% of interns reported having participated in some prior mindfulness training, and 36% endorsed weekly or monthly mindfulness practice in the 12 months preceding intern year before curriculum implementation. At 6 months after completion of the curriculum, 80% (34 out of 42) of interns reported attending at least three of the seven mindfulness sessions. Sixty-nine percent (29 out of 42) of interns had a more positive attitude toward mindfulness, while 62% (26 out of 42) reported yes to having (1) greater knowledge about the scientific evidence behind mindfulness and burnout, (2) improved knowledge on how to apply mindfulness to their lives, and (3) the belief that the mindfulness techniques they learned had positively impacted their lives. Finally, 33% of subjects (14 out of 42) endorsed using mindfulness techniques more frequently in their lives after the curriculum, compared with the frequency they had used related techniques before exposure to the curriculum. Qualitative Results We collected 102 plus and 91 delta responses. Six themes emerged from analysis of plus responses, and eight emerged from delta responses. Plus themes highlighted the positive qualities of the curriculum. First, residents saw curricular implementation as a demonstration of the residency's commitment to physician wellness. Residents appreciated the protected time to develop wellness skills, as well as the opportunity to share their experience with peers. Sessions offered cognitive benefits and a chance to escape from stressful work environments as well as practical, applicable skills for interns' everyday lives. Samples of quotes arranged by category included the following: • Positive notes on the residency prioritizing wellness: ○ “Appreciate the program prioritizing mindfulness.” ○ “Clear program emphasis on wellness.” • Cognitive benefits of the curriculum included increased energy, relaxation, focus, and calm: ○ “Relaxing, skill building for stress management.” • Valuable to escape stressful clinical work and engage in social time with peers: ○ “Chance to relax during a busy day with friends.” • Positive feedback was both global and specific, with references to distinct session characteristics: ○ “Good skill to use ‘Leaves [on a Stream]’ in the future.” • Enjoyed learning new skills that were applicable to their lives: ○ “Demonstrated a useful tool that we can apply on our own.” • Appreciated a safe space in which to share experiences: ○ “I liked the reflection and hearing other people's stories.” ○ “Safe space to share stories.” Delta themes highlighted some of the challenges in creating a one-size-fits-all curriculum, including delivering a curriculum that catered to diverse baseline participant skill levels, learner needs, and preference for curricular structure. Interns emphasized the importance of a conducive physical environment and recommended expanding the curriculum to include more sessions or tools for home practice. Some participants, on the other hand, had no complaints. Samples of quotes arranged by category included the following: • Qualities of the environment, participants' state of mind, and lack of preparation detracted from the experience: ○ “Felt vulnerable with everyone here.” ○ “Phones, pagers distracting!” • Some had no complaints, and only one intern mentioned preference for typical didactics: ○ “Plus: that we did this, Delta: that we don't do this every day.” • Interns differed in desired level of session complexity: ○ “Too meta/cognitively challenging.” ○ “Maybe more complexity to really mimic our daily clinical stresses.” • Requested adaptations for an audience with diversity of experience: ○ “Too many assumptions that we do not do this [already].” • Desired practical strategies for incorporation of mindfulness skills into their everyday lives: ○ “Would have loved to hear more suggestions on incorporating it into day-to-day life.” • Some preferred shorter mindfulness components or more time for socializing: ○ “Would have liked more social time before starting (good for mental health).” 

At baseline, 50% of interns reported having participated in some prior mindfulness training, and 36% endorsed weekly or monthly mindfulness practice in the 12 months preceding intern year before curriculum implementation. At 6 months after completion of the curriculum, 80% (34 out of 42) of interns reported attending at least three of the seven mindfulness sessions. Sixty-nine percent (29 out of 42) of interns had a more positive attitude toward mindfulness, while 62% (26 out of 42) reported yes to having (1) greater knowledge about the scientific evidence behind mindfulness and burnout, (2) improved knowledge on how to apply mindfulness to their lives, and (3) the belief that the mindfulness techniques they learned had positively impacted their lives. Finally, 33% of subjects (14 out of 42) endorsed using mindfulness techniques more frequently in their lives after the curriculum, compared with the frequency they had used related techniques before exposure to the curriculum. 

We collected 102 plus and 91 delta responses. Six themes emerged from analysis of plus responses, and eight emerged from delta responses. Plus themes highlighted the positive qualities of the curriculum. First, residents saw curricular implementation as a demonstration of the residency's commitment to physician wellness. Residents appreciated the protected time to develop wellness skills, as well as the opportunity to share their experience with peers. Sessions offered cognitive benefits and a chance to escape from stressful work environments as well as practical, applicable skills for interns' everyday lives. Samples of quotes arranged by category included the following: • Positive notes on the residency prioritizing wellness: ○ “Appreciate the program prioritizing mindfulness.” ○ “Clear program emphasis on wellness.” • Cognitive benefits of the curriculum included increased energy, relaxation, focus, and calm: ○ “Relaxing, skill building for stress management.” • Valuable to escape stressful clinical work and engage in social time with peers: ○ “Chance to relax during a busy day with friends.” • Positive feedback was both global and specific, with references to distinct session characteristics: ○ “Good skill to use ‘Leaves [on a Stream]’ in the future.” • Enjoyed learning new skills that were applicable to their lives: ○ “Demonstrated a useful tool that we can apply on our own.” • Appreciated a safe space in which to share experiences: ○ “I liked the reflection and hearing other people's stories.” ○ “Safe space to share stories.” Delta themes highlighted some of the challenges in creating a one-size-fits-all curriculum, including delivering a curriculum that catered to diverse baseline participant skill levels, learner needs, and preference for curricular structure. Interns emphasized the importance of a conducive physical environment and recommended expanding the curriculum to include more sessions or tools for home practice. Some participants, on the other hand, had no complaints. Samples of quotes arranged by category included the following: • Qualities of the environment, participants' state of mind, and lack of preparation detracted from the experience: ○ “Felt vulnerable with everyone here.” ○ “Phones, pagers distracting!” • Some had no complaints, and only one intern mentioned preference for typical didactics: ○ “Plus: that we did this, Delta: that we don't do this every day.” • Interns differed in desired level of session complexity: ○ “Too meta/cognitively challenging.” ○ “Maybe more complexity to really mimic our daily clinical stresses.” • Requested adaptations for an audience with diversity of experience: ○ “Too many assumptions that we do not do this [already].” • Desired practical strategies for incorporation of mindfulness skills into their everyday lives: ○ “Would have loved to hear more suggestions on incorporating it into day-to-day life.” • Some preferred shorter mindfulness components or more time for socializing: ○ “Would have liked more social time before starting (good for mental health).” 

These findings demonstrate the feasibility, acceptability, and value of implementing a novel, seven-session mindfulness curriculum in a pediatric residency program. Prior to our curriculum, half of residents reported no prior experience with mindfulness despite its many demonstrated positive benefits. After the curriculum, residents' understanding of mindfulness and their intentions to use it to prevent burnout were higher, and their attitudes toward mindfulness were more positive. One important feature of our curriculum is that it was designed by a pediatric intern for other interns. This unique perspective in creating sessions directly applicable to the busy lives of residents was an invaluable one that allowed the sessions to achieve maximal pertinence and practicality. Furthermore, this quality of the curriculum was lauded in our plus/delta resident feedback. Our curriculum was low cost, could easily be incorporated into previously scheduled didactic time, and required minimal preparation to deliver. Facilitators needed no prior expertise or experience in mindfulness, and anecdotally, facilitators enjoyed the experience so much that they proactively asked to be involved in subsequent years. An additional, unanticipated consequence of the curriculum above and beyond the benefit of mindfulness techniques themselves was residents' perception of a greater investment and buy-in into resident wellness by the residency program overall; this enhanced sense of good will likely positively benefit interns' well-being in other unmeasured ways. Lastly, while designed specifically for interns within our own large pediatric residency program, the content is pertinent to and could be implemented for residents in any size program or clinical specialty. Our qualitative plus/delta data were critical to further elucidating qualities of mindfulness curricula that are important to resident satisfaction, including optimizing environment and content, quality of group work and facilitation, and the importance of shared reflection. Experience with this curriculum over time has shown that identifying a physical location with relative privacy and minimized distractions is important to interns' comfort and full participation; at our home institution, interns were sometimes interrupted with urgent clinical tasks mid-session. Thus, we recommend asking supervisors or attendings to hold pagers and phones, if possible, and rigorously enforcing this policy. Additionally, while those implementing our curriculum may find it appealing to bypass the first 20 minutes of social time to shorten the sessions, we found this transition time critical to ensuring all participants were ready to engage actively in the subsequent mindfulness activities and discussion. It also allows latecomers to participate fully. While not a barrier at our own institution, finding enough facilitators for frequent monthly sessions may be challenging at other institutions. Partnering with adjacent residency programs or representatives from a GME wellness program may afford a larger pool of interested facilitators who can flex in and out throughout the curriculum. Lastly, interns consistently asked for more sessions and resources to support mindfulness practice on a regular basis throughout the year. We addressed this issue by interpolating a 10-minute mindfulness refresher midway between MINdI sessions for all residents during regularly scheduled lunchtime didactics . Our institution also recently invested in access to the HeadSpace smartphone app for all trainees and employees. Others may choose to teach additional mindfulness techniques by extending the curriculum beyond seven sessions as their curricular structure allows. Our pilot study is limited by its single-center design and small sample size. Furthermore, our study utilized self-reporting of the understanding of and intention to practice mindfulness, as opposed to objective measures. Implementation of the curriculum requires a minimum amount of regularly scheduled protected time within a residency didactic curriculum, which some programs may find difficult amidst an already compressed schedule. Lastly, our study was not powered to detect true differences in rates of burnout before or after the intervention. Of note, our educational team is currently conducting a national, randomized controlled trial to better elucidate how this curriculum can affect objective measures of burnout, mindfulness, and empathy among pediatric trainees. We are hopeful that feedback and data from this trial will allow us to better understand the strengths and limitations of the curriculum as it is applied in different residency settings. Despite these limitations, our study succeeds in demonstrating our intervention's feasibility, acceptability, and positive impact on residents. MINdI is an easy-to-implement, facilitator-friendly, and low-cost educational mindfulness innovation that takes into account competing educational priorities, limited time, and potentially limited topic expertise while positively impacting wellness among pediatric trainees. Enhancements to this resource in the future will focus on finding sustainable strategies to optimize the physical learning environment, increasing opportunities for shared reflection among residents, and creatively supporting mindfulness practice beyond just seven sessions. Although mindfulness is not a one-size-fits-all solution to burnout prevention, it can be a powerful intervention for many to improve wellness and resilience and ameliorate burnout. Implementation of similar curricula elsewhere holds great potential to arm house staff with a powerful tool to achieve a sustained reduction in burnout. 

MINdI Facilitator Guide.docx Session Materials Guide.docx The Science of Burnout and Mindfulness.pptx Mindfulness - Being Fully Awake in Our Own Lives.mp4 Body Scan.mp3 Leaves on a Stream.mp3 Sitting Meditation.mp3 Mindfulness and Awareness of Communication.pptx Intro to Insight Dialogue Guidelines.mp3 10-Minute Mindfulness Refresher.mp3 All appendices are peer reviewed as integral parts of the Original Publication. 

