Mindful Practice
Medicine has come a long way from its early days. We’ve evolved from the theory of the four humors into the era of genetics, big data, and even individualized care. Despite all of this change and evolution, it is the doctor-patient relationship which remains at the core of what we do. Unfortunately, this relationship is being eroded by metrics, EMRs, constant interruptions, and the hundreds of other tasks asked of physicians. One way to combat this is by being mindful in our practice and attentive to our patients and their needs. A framework for this has been put forth by Ronald Epstein, MD in his book “Attending: Medicine, Mindfulness, and Humanity.” Below is my interpretation of some of these core attributes and how we might be able to integrate them into our practice to be more mindful and humanistic physicians.
Attentive Observation
Most of us have heard and read about the way doctors think. When we discuss this idea we frequently talk about pattern recognition, thin splicing, thinking fast/slow, and cognitive errors. Almost everyone has heard of the famous study in inattention blindness where trained radiologists missed the image of a gorilla superimposed onto lung scans. Just as we can become blind to small clinical details when faced with large amounts of input, we can easily lose touch with our patients’ emotional needs in favor of their clinical condition. Attentive observation is rooted in looking for and understanding that which our patients need in the moment, recognizing emotional cues and responding to them, and addressing their unspoken needs.
It has been well documented that physicians miss opportunities to recognize and address emotional distress in patients. From the surgical professions to primary care, physicians continuously miss opportunities to respond to our patients’ emotional needs and distress with empathy. Many times, it is because these opportunities go unrecognized by clinicians who are all too focused on addressing clinical issues. Unfortunately, patients notice this disconnect, they feel unheard, and are less likely to be forthcoming with critical information or adhere to recommendations. Fortunately, it is possible to train ourselves to be better about this. Mindfulness exercises and focused attention can help us to be more in touch with our patients. In much the same way that “exertional chest pain” or “thoughts of self-harm” trigger red flags — with practice — we can condition ourselves to trigger the same red flags when our patients express fear, doubt, or uncertainty and we can respond with compassion rather than clinical objectivity.
Critical Curiosity
Everybody in medicine has an innate sense of curiosity, otherwise they wouldn’t be in their current position. For a select few, this curiosity will lead to the next great scientific discovery or cancer breakthrough, but for the majority it is best applied at the bedside. We can harness our curiosity in two ways; 1) to dive deeper into a history or case presentation to reach an elusive diagnosis and 2) to learn more about our patients and see them as more than a case study. We all know how to apply our curiosity in the first sense, this is what allows us to be excellent diagnosticians. Those who engage their curiosity in latter sense are the truly masterful clinicians. When we engage our patients and come to see them as a person experiencing a disease, we can better tailor our treatments. Perhaps that patient needing antibiotics can’t take a pill four times a day because they work in the back country and would rather pay more for a once daily medication. Or perhaps that person with the bad left ankle sprain is cleared to work from an orthopedic perspective, but now needs a longer excused absence since they can’t safely get to work because they drive a manual transmission car.
Being curious about our patients and truly engaging with them isn’t always easy. There are some patients that will rub you the wrong way, are vague historians, keep bouncing back to the ED, or provide a rambling history chronicling back to the second grade. While these encounters can be frustrating at times, they also represent a chance to engage our curiosity for the betterment of our patients. Although it requires a bit of mindfulness and self-awareness to recognize moments where we are getting distracted or frustrated, once we do we can purposefully apply our sense of curiosity. Curiosity is what allows us to link together our attention, knowledge, and ability to explore with our patients to identify the issue at hand and come up with a resolution.
A Beginner’s Mind
This is a Zen concept which allows us to harness our expertise while at the same time seeing each patient with fresh eyes and an open mind. Everyone is inherently familiar with the concept of the beginner’s mind — we’ve all experienced it as we were learning something new or trying something for the first time. The beginner’s mind is empty, free of the habits and shortcuts of an expert, ready to accept, ready to doubt, and open to possibilities. The beginner’s mind doesn’t know what it doesn’t know, and because of this is capable of seeing things as they are rather than as they “should be.” This stands in stark contrast to the expert’s mind, full of preconceived notions — an expert recognizes patterns, takes shortcuts, knows the answers and what to expect from a situation. Unfortunately, this expert perspective can blind us when trying to solve problems in a phenomenon known as the Einstellung effect (not being able to see a new or simpler solution because of a fixed/rigid mindset or perspective).
A master clinician is one who has learned to harness the beginner’s mind. We should strive to intentionally set aside our expert selves and embrace the beginner’s mind when meeting with a patient. In doing so, we can see each patient and each encounter with a fresh perspective and be open to all the possibilities rather than assuming more of the same (i.e assuming that doctor knows best, perpetuating diagnoses/labels, and minimizing patients with frequent ED presentations). After evaluating a patient from a beginner’s perspective, we can then consult our expert selves and meld the two together to render a better clinical impression and plan.
Presence
Presence, or really being there, is a difficult notion to define. It is one of those “you know it when you see it” things that we’ve all experienced in everyday life. Presence is the sense of connectedness between two persons, it is listening and truly understanding, or seeing and truly knowing. It isn’t something measured in minutes, but rather in moments – that second when time stands still when watching a performance or listening to music, that half second touch or embrace that seems to last a lifetime. Being present means feeling and knowing the humanity of those you are with while you are together. While presence may seem an elusive concept, its absence can be easy to identify, and we should strive to cultivate it with our patients.
It can be all too easy to maintain a sterile and safe distance from our patients under the guise of professional objectivity and being imperturbable clinicians. Unfortunately, the “clinical gaze” can force us to see our patients as a sum of their problems, conditions, medications, and surgeries rather than the human beings that they truly are. We can combat this when interacting with our patients by creating a space that allows for presence and connectedness. To cultivate presence with our patients we should set aside our multitasking, parallel processing minds when entering the room and focus on the patient in front of us. Greet them warmly with a smile, gentle gaze, and sincere (rather than perfunctory) handshake. Sit down, allow them to speak and refrain from interrupting. Address their family and loved ones, notice and respond to cues for empathy, fear, and uncertainty. Harness the power of silence in your interactions. These simple steps help to set the stage and create a space where moments of presence can emerge between us and our patients.
Conclusion
It is my hope that by thinking about these four concepts we can all become more mindful and humanistic physicians. As we all know, practicing clinical medicine is difficult and fraught with frustrations, barriers, and burnout. While no easy solution to these issues exists, I firmly believe that we can renew ourselves and combat these problems by finding joy in our patients and our interactions. By embracing our roots as compassionate healers and patient advocates we can better connect with ourselves and those we care for.
AUTHOR: Joshua Kaine, MD
FACULTY REVIEWER: Gita Pensa, MD
References
· Epstein R. Attending: Medicine, Mindfulness, and Humanity (New York: Scribner 2017)
· Chabris C and Simons D. The Invisible Gorilla: How our intuitions Deceive Us (New York: Crown 2011)
· Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med. 2008 Sep 22;168(17):1853-8. doi: 10.1001/archinte.168.17.1853. PMID: 18809811; PMCID: PMC2678758.
· Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. "Could this be something serious?" Reassurance, uncertainty, and empathy in response to patients' expressions of worry. J Gen Intern Med. 2007 Dec;22(12):1731-9. doi: 10.1007/s11606-007-0416-9. Epub 2007 Oct 31. PMID: 17972141; PMCID: PMC2219845.