Eventually I wanted to translate what I had learned about the inner life so that I could make a difference in the world, and I reconnected with a childhood desire to be a doctor. Yet I was ill prepared for the culture of medical school. I had spent much of my youth in seminars, music studios, and Zen meditation halls. Med school was an environment of extremes. Altogether, I saw too much harshness, mindlessness, and inhumanity. Medical school was dominated by facts, pathways, and mechanisms; residency was about learning to diagnose, treat, and do procedures, framed by a pit-of-the-stomach dread that you might kill someone by missing something or not knowing enough. Given the life-and-death stakes, I found it jarring that, with few exceptions, medical training did not emphasize deep listening—to oneself or to others. While extolling the virtues of reflection and compassion, medical training largely ignores the development of these capacities—and an inner life in general. I felt disappointed and alone and didn’t see a path forward.
Then, Reich sent me a groundbreaking article by George Engel about a “biopsychosocial” approach to care.10 Engel was a prominent internist and psychoanalyst who practiced and taught at the University of Rochester. I wrote to him, and eventually he became a mentor. Engel showed, through exploring patients’ illness experience, how patients’ psychological makeup and social relationships were as important to illness and health as the biological, genetic, and molecular aspects of disease. His vision was humanistic; using dazzling illustrations, Engel demonstrated that what the patient reported about his illness and how it affected him was as important as any lab test or X-ray. Engel emphasized that physicians are human too—that their emotional responses to uncertainty, tragedy, grief, and loss would affect the care they provide.11 This resonated with me. Doctoring was a relationship between two people, each of whom had an inner life. I moved to Rochester and worked with Engel and several of his protégés. Engel was fascinated with human experience, but, in my view, was too much of the cold scientist to offer a method for knowing one’s inner life more intimately. Several of his protégés filled that role for me. Trained by Engel, they took his work one step further and offered opportunities for reflection, self-awareness, and mindfulness (so-called Balint groups,12 family-of-origin groups,13 personal awareness groups,14 and clinical supervision15) that were available in few other settings at the time.
Over time I became more comfortable with my level of knowledge and skill as a clinician, yet I still knew that each day, with each patient, sometimes I was the physician I aspired to be and other times I fell short. Falling short had little to do with knowledge and technique, but rather it had to do with my state of mind, what I noticed and attended to. Sometimes I practiced with clarity and compassion, and other times impatience, distraction, unexamined emotions, and defensiveness got in the way.
Lacking a guidebook, I had to look inside myself. Then I’d match up my states of mind with what I had been learning about the sciences of mind—psychology, philosophy, education, and neuroscience. Wading through a profusion of educational and psychological jargon,16 I came to three conclusions—good doctors need to be self-aware to practice at their best; self-awareness needs to be in the moment, not just Monday-morning quarterbacking; and no one had a road map.17
Ten years after I finished my residency, the connections between my prior training in meditation and music and my medical practice finally crystallized. My dean tasked me with developing a new method for assessing the competence of students that would reflect the biopsychosocial values that Rochester had become known for—no small undertaking. I could find few guideposts, not even a coherent definition of professional competence.18 I wanted to capture the habits of master clinicians, those to whom doctors might refer a friend or relative, as opposed to those who were merely competent—those who merely aced the test.19 I started writing about “mindful practice”; I drafted a personal manifesto about excellence in clinical practice and proposed that mindful self-awareness, self-monitoring, and self-regulation were at the root of good judgment, compassion, and attentive care. I had not seen a similar vision articulated before, and I had no idea how it would be received.
The manuscript went back and forth to the Journal of the American Medical Association seven times, and each time Charlene Breedlove, my insightful and patient editor, asked me to clarify, hone, and condense before “Mindful Practice” finally went to press in 1999.20 The article struck a chord. I discovered that I was not alone. I received hundreds of letters and e-mails from other physicians. These practitioners, many of whom had found some form of contemplative practice on their own, felt isolated and in need of a community that would support their efforts to become more mindful, resilient, self-aware, and effective. I was deeply gratified, yet the next steps—to see if mindfulness makes a difference in patient care and how to help clinicians be more mindful—were daunting.
IN THE CLINIC
My colleague Dr. Mary Catherine Beach, at Johns Hopkins, helped to provide an answer. She studied interactions between patients and doctors in AIDS clinics around the United States.21 People with HIV/AIDS often feel stigmatized and misunderstood, and not surprisingly, many are distrustful of the health care system. Beach and her team audio-recorded visits between doctors and patients and surveyed them afterward, including assessments of mindfulness. Physicians who were more mindful did better at developing rapport, following up on patients’ concerns, and addressing psychosocial issues; their patients felt better understood, more connected, and emotionally supported. Mindful physicians won their patients’ trust, no trivial matter. A patient’s trust in her physician is the best predictor of whether she will take her medications, a crucial factor if you’re HIV infected. Missing even a few doses could allow the virus to replicate and become drug resistant. Connection, understanding, and trust are essential.
Still, Beach’s study did not answer whether practicing physicians could be trained to be more mindful and, if so, whether they would provide better care. For years it had been known that mindfulness training could help patients with a variety of mental and physical disorders. Yet the idea of mindfulness for physicians to enhance their own work was new. I found like-minded colleagues—Mick Krasner, Tim Quill, Tony Suchman, Howard Beckman, and others at the University of Rochester—and together we designed a year-long program in mindful practice for experienced primary care physicians.22 The sessions included different kinds of meditation practice and exercises to promote mindful communication, emphasizing how to bring mindfulness into clinicians’ everyday work to help them be attentive and aware. Each session touched on a particular issue—responding to errors, witnessing suffering, facing uncertainty, grieving the loss of a patient, developing compassion, feeling attracted to patients, and others. We also addressed clinician burnout directly, knowing that burned-out physicians provide lower-quality care and are more likely to quit practice altogether. We drew a simple model of what we were trying to do—the technical quality of care, the qualities of caring, and clinicians’ resilience and well-being—showing how these three domains were linked and how practicing mindfully could affect all three. We started out with a group of seventy physicians, nearly all of whom scored high on a burnout questionnaire. We didn’t know if they’d have the energy and commitment to finish the program or if it would show any positive effects at all.
The results far exceeded our expectations.23 Physicians’ well-being improved and their burnout decreased. They became more empathic and oriented toward their patients’ psychosocial needs. We were astonished that they scored higher on conscientiousness and emotional stability, key features of personality that aren’t supposed to change in people in their forties and fifties (more about this in chapter 10).24 They became more attentive and focused, less likely to be derailed by crises, and better able to rely on their inner resources to remain resilient. We interviewed some of the doctors a year later. They continued to affirm that cultivating a practice of mindfulness, creating a community of supportive colleagues, and giving themselves permis
sion to focus on their own growth made them better physicians. They reconnected with the reasons they went into medicine in the first place: to provide effective and humanistic care, and to have meaningful relationships with their patients.25 They set limits and had a more balanced work life.
A MINDFUL VISION
Medicine is in crisis. Physicians and patients are disillusioned, frustrated by the fragmentation of the health care system. Patients cannot help but notice that I spend more and more time looking at computer screens and less time face-to-face.26 They experience the consequences of the commodification of medicine that has forced clinicians’ focus from the healing of patients to the mechanics of health care—productivity pressures, insurance regulations, actuarial tasks, and demoralizing metrics that measure what can be counted and not what really counts, sometimes ironically in the name of evidence-based and patient-centered care.27
I have seen that it is possible to do better, and that is the reason I’m writing this book. Amid this crisis in health care, some physicians are making choices to reacquaint themselves with the heart of medical practice. By looking inward, they are expanding their capacity to provide high-quality care. They are seeing how they, as doctors, have the power to transform and humanize the practice of medicine and how patients can be better consumers of health care, build stronger relationships with their physicians, and identify those who can provide the care they need.
Mindful practice in medicine is more than meditation and personal growth.28 Being mindful is when I know to stop briefly, look a patient in the eye, and ask, “Have I got it all, or is there more?”—and a patient, whose previously well-controlled diabetes is now uncontrolled, then tells me he hasn’t been taking care of himself since his wife died six months ago. It’s when I inject an inflamed shoulder joint—with focused attention, visualizing the bones, tendons, and muscles—and the needle slides in easily and painlessly. I’m being mindful when I notice that a patient doesn’t look quite right, not her usual self, and then I notice the fatigued expression and the faint rash that are clues to her new diagnosis of lupus. Attending to each patient means that I remember that, although the last patient I saw has only days to live, the next patient—with a stubbed toe—needs the same focused attention.
Medicine and meditation, etymologically, come from the same root: to consider, advise, reflect, to take appropriate measures. But while I can try to describe what being mindful is like, words carry just so far; ultimately, mindfulness is an experience—something that we have all encountered at some moment. Perhaps, as you are reading, you might periodically stop for a moment and become aware of your own body and your thoughts, emotions, and expectations; be aware of how present, curious, engaged, and attentive you are feeling. Over time, you will know yourself better. For starters, let this be an invitation to know the lens through which you view the world.
2
Attending
You can observe a lot by just watching.
—Yogi Berra1
Emil Laszlo, a sixty-six-year-old Hungarian-American engineer, had been a patient of mine for several years. An avid tennis player, he had had few medical problems other than a bout of rotator-cuff tendinitis of his right shoulder two years prior. Upon my return from a trip, I was surprised to discover an urgent voice mail from his wife. Emil was in the hospital. I called her back and she explained that the doctors suspected that he had cancer. But she was confused because they had seen three different clinicians in my absence, and after each visit to our clinic they had left with the idea that his right shoulder pain was nothing more than a recurrent rotator-cuff problem.
I investigated his chart for clues. On his first visit he saw one of my practice partners. The chart noted that Emil had pain in his right shoulder and it felt as if “there was a swelling there.” The physical exam confirmed tenderness and pain on motion, but there was no description of the “swelling.” Unlike two years before, though, he did not have some of the typical signs of rotator-cuff tendinitis—such as decreased range of motion or muscle weakness. It wasn’t unreasonable to think that this might be a recurrence of his tendinitis; weakness and restriction of motion might not be present early in the clinical course. He was sent home with typical advice for rotator-cuff injuries: a prescription for a nonsteroidal anti-inflammatory medication and physical-therapy exercises. Yet the chart also mentioned that Emil felt feverish and had had a few night sweats. Perhaps because it was flu season, I presume, his doctors had a convenient explanation.
At Emil’s second visit to our office, the physician noted a “prominence” near the shoulder. Again, full range of motion. She attributed the “history of night sweats” to a “viral syndrome.” Emil also came with several additional concerns: mild prostate-related symptoms, fatigue, and a low vitamin D level. She encouraged him to continue with physical therapy and anti-inflammatory medications, and I can only assume that she thought that the prominence was related to his rotator-cuff problem. Notably, she did not call it a “lump” or a “mass” or anything that might connote something more serious.
On the third visit, he reported worsening fatigue, more than you would expect from the flu. His pain was worsening despite medications and exercise. Yet, the chart still didn’t mention a mass. The nurse-practitioner homed in on his disabling fatigue and ordered some blood tests. The results showed an extremely low white blood count. She called Emil at home and sent him to the emergency room. Only then, after the blood test suggested something serious might be going on, was the ten-centimeter tumor extending from his armpit to his shoulder finally “seen.” In hindsight it all made sense—pain, a mass, and fatigue are typical for lymphoma—but all three clinicians were stunned by the news and were at a loss to explain how they could have missed something so obvious.2
Every day, clinicians fail to attend to something that seems obvious in hindsight. Emil’s situation got me wondering why. Clinical care is fast paced. Amid a deluge of patients with potentially preventable acute problems, poorly controlled chronic diseases, and intractable mental health issues, and whose uncooperative insurance companies won’t pay for medicines they need, Emil arrives. To his physician’s relief, Emil seems to have a problem that is straightforward and easy to solve. I wondered if his clinicians’ (mis)diagnoses had to do with misperception (Did they not even look or did they look and not really see the tumor?), misinterpretation (Did they see it yet misjudge its significance?), misprioritization (Because it didn’t “make sense” was it relegated to secondary status?), or closed-mindedness (Having arrived at one explanation, did the clinician lose interest in seeking out alternative explanations?). All of these factors can contribute to what psychologists call inattentional blindness.
We all experience inattentional blindness in everyday life. Often it is of little consequence; you find your keys in the place where you just looked. Other times it is more serious. A friend of mine had a rear-end collision on a sunny fall morning; he was talking on his hands-free mobile phone and didn’t see the car right in front of him. Or take this well-known example: In a video that has gone viral, players dressed in black outfits and white outfits toss a basketball, and the viewer is instructed to count the number of passes between the players in white. The majority of viewers are oblivious of someone in a black gorilla suit moonwalking across the set—until it is pointed out to them.3 It had been filtered out. Filtering is a neurologic necessity to keep us from being overwhelmed by all the stimuli from the environment; below our awareness, our brains make choices, usually the right ones, but sometimes the wrong ones—especially when the stimulus is unexpected.
Even those who are exquisitely trained to look for visual details miss the unexpected. In one study, a researcher asked radiologists to view a chest CT scan on a computer screen. A small gorilla figure was strategically placed in one of the images. More than three-quarters of the radiologists didn’t notice the gorilla. Unbeknownst to the radiologists, the computer had sophisticated visual-tracking technology that confirmed that the
ir eyes had looked directly at it.4 Their inattentional blindness had little to do with knowledge and years of experience.
Inattentional deafness works the same way: it’s an auditory glitch in which we don’t hear things that are clearly said to us. More than once I’ve had a worried parent bring a child to my office for a hearing test, hoping for an explanation for why the child doesn’t respond when spoken to, only to find that the hearing is perfect. (This happens with married couples too!) As a clinician, I can so easily not hear the unexpected and the unwanted. Like inattentional blindness, it can be benign or life-threatening; in the operating room, it could be fatal.5
How can this happen? Research shows how focusing intensely on a visual task—in the operating room or looking at a computer screen—interferes with our ability to listen.6 The reverse is likely true too; that is why talking on cell phones while driving—even with hands-free devices—leads to accidents. We can’t pay attention to everything all the time. Like computers, our brains have a limited capacity for working memory—that which we can hold in our awareness at any given moment—and our brains are constantly making choices. More accurately, we prioritize that which is personally meaningful and ignore sensory input that we consider to be of low value—information that is inconsistent with our expectations or information that comes from a presumably unreliable source (such as a third-year medical student). The problem is that these “choices” are usually below our levels of awareness, and thus we don’t routinely assess the rational or irrational factors that go into making them.
NOT SEEING, NOT KNOWING
The great physician-teacher William Osler once said, “We miss more by not seeing than by not knowing.” It may sound trivial, but simply paying attention is one of the most difficult tasks for clinicians. It’s no secret that much of what physicians do is routine. Reading an electrocardiogram or prescribing medications for hypothyroidism or heart failure is often done by protocol, and to save working memory, our brains make most of those tasks automatic, or nearly so. We use what psychologist Daniel Kahneman calls Type 1 processing, or fast thinking.7 Anyone, even without a medical background, could easily learn the symptoms and treatments for urinary tract infections and get it right about 80 percent of the time. But in 20 percent of the situations, something atypical appears and requires that doctors switch out of autopilot and apply a more conscious, focused attention, what Kahneman calls Type 2 or slow thinking. Medical training is long and arduous largely to help doctors deal with the 20 percent, the unexpected and complex situations that require more than just knowledge, technical skills, and years of experience.8 Yet doctors aren’t trained to notice and make the switch from automatic thinking to a slower—more deliberative—mode. It’s easy not to notice the unexpected, especially once we’ve committed ourselves to a provisional idea about what might be going on.
Attending Page 2
