Getting back to basics

May 14, 2022

by Ron Epstein, M.D.

Frequently I am asked to describe how practicing mindfully is integral to good medical practice, yet it is sometimes difficult to put it into just a few words. I had one opportunity recently. Bill Ventres, a friend and family physician, is putting together a book of “philosophies” of medicine and asked me to write a chapter. It was a difficult assignment: no more than 500 words, no more than one picture. I procrastinated, choosing to write longer pieces instead, much easier than writing a short piece.

Then, I realized that procrastination was actually my friend – through distractions and daydreaming, putting things off and writing and rewriting, I came to a new clarity. I might not have put it all this way had I been provided the same opportunity even a few years ago. Like all important ideas, it grows and evolves and has a life of their own, and we only catch glimpses of its truth. So, here is mindful practice, with a date stamp, May 2, 2022:

Mindful practice refers to a moment-to-moment purposeful attentiveness to one’s inner life—thoughts, sensations, emotions and mind—during every day work with the goal of practicing with clarity, skill, wisdom, and compassion.

The word “mindfulness,” derived from the ancient Pali language, connotes “remembering,” originally characterized as “right mindfulness.” Applied to clinical practice, right mindfulness is a practice to help us remember and enact our values and aspirations in the chaos and uncertainties of clinical medicine. It is a vector, pointing to attitudes of mind—attentive observation, critical curiosity, beginner’s mind, and presence—that we can cultivate to promote pro-social goals: listening to understand and not merely respond, enabling and empowering patients toward health, being technically adept, recognizing and responding to our own errors, communicating effectively in emotionally charged and conflict-ridden situations, engaging in compassionate actions even when they are not required by our professional codes, and self-care in order to sustain ourselves and be available to those who need us the most.

Four qualities of mindful practitioners are particularly relevant in clinical medicine.1 First is attentive observation of oneself and the environment, recognizing that “we don’t see things as they are; we see things as we are.”2 Knowing the lens through which we view the world (and ourselves) opens up the possibility of recognizing our cognitive biases and emotional triggers, and, through taking a pause, recalibrating ourselves to appreciate things as they are, not how we would have them be.

Second, critical curiosity is the capacity to remain open, actively seeking new information, taking interest in the person, the illness and their contexts.3,4 Remaining curious is particularly important—and challenging—when we feel stressed, facing uncertainty and ambiguity, or encountering unforeseen negative experiences.

Third, beginner’s mind refers to the capacity to appreciate novelty in the familiar, to see a situation from more than one perspective, and avoid premature closure. Recognizing that “in the beginner’s mind the possibilities are many, in the expert’s mind they are few,”5 we become as interested in the questions as in the answers, and think outside the confines of our current understanding.

Fourth, presence refers to a quality of “being there,” the exhilaration of being immersed in a task, and—of critical importance when practicing medicine—a sense of shared mind and authentic feeling with patients, families, and colleagues that “occurs in the space between them as much as in their emotions.”6    

Importantly, mindful practice can be taught and cultivated through individual and shared contemplative practices, learning how stressors impact our functioning and well-being, sharing narratives of meaningful events in clinical practice and deep listening. Through developing habits of mindfulness during the workday we can promote quality of care, connection with others, and clinician well-being.7-10

For further reading

Epstein RM. Attending: Medicine, Mindfulness, and Humanity. NYC: Scribner; 2017

References

1.         Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.

2.         Nin A. The Diary of Anais Nin, 1939-1944. New York: Harcourt, Brace & World; 1969.

3.         Dyche L, Epstein RM. Curiosity and medical education. Medical Education.       2011;45(7):663-668.

4.         Fitzgerald FT. Curiosity. Ann Int Med. 1999;130(1):70-72.

5.         Suzuki S. Zen Mind, Beginner’s Mind. New York: Weatherhill; 1980.

6.         Kleinman A. Presence. The Lancet. 2017;389(10088):2466-2467.

7.         Beckman HB, Wendland M, Mooney C, et al. The impact of a program in mindful     communication on primary care physicians. Acad Med. 2012;87(6):1-5.

8.         Epstein RM, Marshall F, Sanders MR, Krasner MS. Effect of an Intensive Mindful Practice Workshop on Patient-Centered Compassionate Care, Clinician Well-Being, Work Engagement and Teamwork. Journal of Continuing Education in the Health Professions. 2021, in press.

9.        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.

10.      Scheepers RA, Emke H, Epstein RM, Lombarts K. The impact of mindfulness-based interventions on doctors’ well-being and performance: a systematic review. Med Educ. 42020;54(2):138-149.

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