Mindfulness

Posted on Dec 13, 2011 in Practice Management | 5 comments

Mindfulness in Medicine

Mindfulness: “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.”
   Jon Kabat-Zinn, Wherever You Go, There You Are [1]

Primary care physicians’ distress levels are alarming, both professionally and personally, with up to 60% reporting symptoms of “burnout”[2]—emotional exhaustion, depersonalization (treating patients as objects), and low sense of accomplishment.[3] This burnout has been linked to a myriad of issues: poorer quality in patient care, patient dissatisfaction, an increase in medical errors and lawsuits, loss of empathy and depersonalization,  and an increase in attrition.[4-6] Physicians who report burnout often feel unable to “be present” with their patients. Without this sense of emotional presence, physicians tend to see their patients as objects of care, rather than as unique and fellow humans, and find it more difficult to respond to their patients’—or their own—emotions during challenging clinical encounters.[7]

An increasingly popular way to addressing these gaps is to develop a mindful practice—in a nonjudgmental way, attending to one’s own physical and mental being during ordinary and everyday activities.[8] Mindfulness is the opposite of multitasking. The traditional goal of mindfulness is to maintain awareness moment by moment, disengaging yourself from distractions and prior attachment to beliefs, thoughts, or emotions, thereby developing a greater sense of emotional balance and well-being.[9] Originating from ancient eastern meditation and Buddhist yoga traditions, mindfulness can be considered a universal human capacity designed to foster clear thinking and open-heartedness that requires no particular religious or cultural belief system.

Mindfulness is generally described as a particular way of paying attention characterized by intentional and nonjudgmental observation of present moment experiences. It’s more than merely a relaxation technique; rather, it is mental training to develop awareness and acceptance skills to cope with daily events that may otherwise lead to heightened anxiety and stress.[10] One physician has described mindfulness as “a quality of the physician as a person, without boundaries between technical, cognitive, emotional, and spiritual aspects of practice.”[8]

The original purpose of mindfulness in Buddhism—to alleviate suffering and cultivate compassion—suggests a potential role for this practice between patients and practitioners. In fact, the connection between medicine and meditation is underscored by their shared word origin from the Latin word mederi, which means “to heal.”[9] As a link between relationship-centered care and evidence-based medicine, mindfulness—or mindful practice—should be considered a characteristic of good clinical practice.[8] As you become a mindful practitioner you become more aware of your own mental processes, you listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion. Mindful practice involves a sense of “unfinishedness,” a curiosity about the unknown and humility in having an imperfect understanding of another’s suffering.[11]

Mindfulness can be practiced in all aspects of daily life, and you can bring moment-to-moment awareness to all activities and to all experiences. Mindfulness is the difference between glancing at the clock three or four times during a patient encounter as opposed to focusing solely on your patient without looking at your watch. It’s also the difference between flipping through your patient’s chart while he talks to you rather than you actively asking him questions. In the former scenario, you’re mentally preoccupied with the patient’s medical history and with choosing a possible diagnosis; in the latter you’re fully attentive as your patient speaks. In the former, your mind is not with the patient at this moment but elsewhere, thinking in the past (medical history) or future (therapy to be described). In the latter, you bring not only your medical knowledge but your whole human presence to the clinical encounter. In this encounter, patients will feel that you’re listening and that they’re accepted for who and what they are. Equally, you’ll gain a better understanding of the specific problems of the patient when really listening, rather than being busy with other cognitive activities. When patients feel accepted, they’re more likely to directly describe their true complaints and problems, again facilitating the communication process.

Mindful practice requires mentoring and guidance. Recognizing your limitations can be emotionally difficult. Medical literature[4,12,13] describes a variety of ways to become more self-aware. You can keep a journal, practice meditation, review videotapes of sessions with your patients, and use learning contracts.[8] In medical education, self-evaluation forms for students and residents have been important adjuncts to the evaluation process. Learners can compare their perceptions with those of a teacher or mentor. In actual practice, try the following: as a new patient is ushered into the exam room, look right at him and say his name to yourself three or four times rather than thinking about the patient you just saw or the challenging patient who is coming in next.

Most clinicians live and practice in a world that is very concrete and 180 degrees from the abstract concepts of mindfulness. Smart phones, e-mail, faxes, and paperwork all compete for our time and attention. It can be a challenge to learn how to shut out the distractions and really concentrate on a patient, on your reading, or even on your leisure time. It takes time and is likely to require more than a glass of wine or a journal entry. But rather than try to embrace the whole concept at once, just remember that basically, mindfulness is just a way to be present for your patients and yourself. It is a disciplined and practiced approach that requires minimal training and lots of ongoing practice. You might just find that by shutting out all the distractions and focusing on the tasks and tensions as they arise, you’ll truly be “where you are.”

Jill Shuman, MS, ELS
Published December 13, 2011

References

1. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York, NY: Hyperion; 2005.
2. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.
3. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
4. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114(6):513-519.
5. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manage Rev. 2010;35(2):105-115.
6. Beat burnout before it beats you. Primary Issues Website. http://www.primaryissues.org/2011/02/beat-burnout-before-it-beats-you/. Published February 22, 2011. Accessed December 12, 2011.
7. Horowitz CR, Suchman AL, Branch WT Jr, Frankel RL. What do doctors find meaningful about their work? Ann Intern Med. 2003;138(9):772-775.
8. Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.
9. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008;300(11):1350-1352.
10. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits. A meta-analysis. J Psychosom Res. 2004;57(1):35-43.
11. Friere P. Pedagogy of Freedom. New York, NY: Rowman & Littlefield; 1998. Cited by: Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.
12. Faye A, Kalra G, Swamy R, et al. Study of emotional intelligence and empathy in medical postgraduates. Indian J Psychiatry. 2011;53(2):140-144.
13. Connelly JE. Narrative possibilities: using mindfulness in clinical practice. Perspect Biol Med. 2005;48(1):84-94.