With training, you can bring these warning signs to your awareness before they get out of hand. Training starts with noticing. Ask yourself, What are some of my early warning signs of distress in the workplace setting? Start with the body. What bodily sensations and behaviors do I notice? Most of the time, we feel these early warnings as bodily sensations—a tightness in the shoulders, a knot in the stomach, shakiness. Next, explore any emotions that accompany those warning signs: What are they? The emotions that often accompany the bodily sensations might be feelings of impatience, fear or anger, and sometimes just a sense of disconnection and blandness. Now, be aware of thoughts, ideas, interpretations, and judgments that accompany these warning signs. Sensations and emotions may be accompanied by specific thoughts—such as thinking that you’re feeling inadequate in some way. You might notice that your behavior is different—you drive faster, eat less, put off important tasks, clean your desk, or buy things you don’t really need—before you consciously register that you are tired, stressed, or annoyed.
One early warning sign for me is when I start making more typos than usual. It’s annoying. I go back and correct the error, then compensate by typing faster. Then I pound harder on the keys, as if I could beat them into submission. It only gets worse. I get angry at the computer (Why is the spell-checker in the medical record so clunky?), then the clinic (Why did they have to schedule three extra patients for me today?), and finally patients themselves (Why does she always come with forty complaints to deal with in a twenty-minute visit?).
Awareness of these early warning signs can provide a window into our inner state before things get unmanageable. I call them “friends”; they are protectors and reminders. When I notice my typing deteriorating, I can stop for a moment and appreciate that I have a choice, a choice I had not previously acknowledged: I can choose to get annoyed at myself and pound harder, or I can summon a state of curiosity, saying to myself, “Oh, here I am making typos. I wonder what that’s about. Am I feeling rushed? Is the task unpleasant? Do I need to feel that way? Is it useful to respond in this way? Can I do anything about it?” It may seem easy to take a new perspective, yet too often all of us just let the pressures mount. Because most of us don’t have habits that constantly put us in touch with the early warning signs of stress, we have to develop them. It takes intention, practice, and discipline—qualities that doctors and most high-functioning professionals often bring to other domains of their lives.
When being mindful, I am aware of how my expectations and emotions condition what I see and that I can take a new perspective or readjust the lens through which I see the world. I engage in metacognition: thinking about and appraising my thinking and emotions. It’s saying to myself, “I’m feeling pretty stressed. What’s that about?” Then asking myself, “Is this situation really altogether negative?” And “Is there something I can learn from it?” I realize that my original view may have been biased or myopic. I recalibrate. Research suggests that those who are able to recalibrate and take a new perspective may grow new neural connections in brain structures associated with emotional intelligence and emotion regulation.36
RESILIENCE TRAINING
Some of the most interesting research on resilience training comes from military settings, with soldiers who were about to be deployed into war zones. I initially had trouble with research about people who were being trained to control and kill—and not to empower and heal—until I realized that I was making assumptions that might not be quite true. In many ways, medical settings resemble military settings. In both health care and the military, the physical and emotional stresses are ongoing and extreme, and the training is rigorous and all-consuming. In both settings, the dictum is “first do no harm” (although I wish that doctors and generals would keep that in mind more often) and not be trigger-happy (medications and surgery can kill as well as heal). In both settings, problems are complex. You need mental stability, effective communication, ethical conduct, and wisdom to manage unexpected situations rarely encountered in civilian life. Both settings have hierarchies that often do more harm than good, bringing a huge risk of disconnection between those who are in charge and those who are on the front lines. Both soldiers and doctors experience vicarious trauma frequently—they witness the unbearable suffering, loss, grief, dismemberment, disintegration, and destruction of people who deserve better. Both professions involve huge personal sacrifices, and reflection and self-awareness are not part of either professional culture.
Military mind-fitness programs with a strong emphasis on meditation practice have had positive effects.37 Participants recovered more rapidly after stressful events. Their heart rates and breathing and stress hormone levels normalized sooner, and they experienced fewer ill effects from subsequent stresses. They made better decisions, had fewer lapses in attention, and were better able to tolerate adversity.
To address the controversy that such programs might just make more attentive—but heartless—killers, the developers of the program have a counterargument: reducing emotional reactivity can reduce the reckless or unethical behaviors that only compound the tragedy of war. They claim that by improving emotional intelligence, soldiers might work as a team and win the hearts and minds of others. I hope that is true. I raise this controversial parallel to medical practice because these studies point to ways in which health professionals and others doing “combat duty” in the public service can become more mindful.
RECAPTURING PURPOSE AND MEANING
Whenever I see a distressed clinician learn to be more resilient, I wonder how she did it. The health care environment has only gotten worse, with more administrative burdens and less social support. The first hurdle is awareness. Diane knew she was distressed, as do most participants in our workshops. They’ve seen the warning signs. Over the course of a year, Diane started a regular meditation practice, just ten to fifteen minutes each morning, and used an app for her smartphone that would remind her and time her sessions. More important, she prompted herself to incorporate mindful moments into her day—a habit of pausing, opening, relaxing—rather than just plowing through. Even brief moments of self-care were powerful reminders to focus more on what was truly important. She adopted a practice of gratitude, each day intentionally naming one thing for which she was grateful; it helped her to recalibrate. Gradually she saw more clearly which external factors she couldn’t change—completing meaningless checklists, wrestling with insurance companies, and dealing with unwieldy electronic record systems—and her attitude changed. She learned that she didn’t have to respond to every request made by patients, administrators, and insurance companies, and she mastered a few more shortcuts so that she could work with the electronic health record system more effectively. She started a small insurrection in her office—she put her photographs on the walls, and others did the same. She realized that the computer screen could be a barrier, so she had the computer screen remounted and rearranged her office so that she and the patient could look at the screen together—it improved communication and helped her to feel more connected with patients, even when she had to type or look something up. These small changes reflected an incremental change of focus and attitude. She was more honest with herself, listened more deeply to patients and colleagues, and felt a greater sense of community. Despite kayaking in rough waters, she felt that she was no longer about to drown.
11
Becoming Mindful
When you practice being mindful, you reshape your brain. Every year, hundreds of scientific articles explore how this happens and under what conditions. But the very idea that the adult brain could be reshaped was radical until thirty years ago; psychologists and neuroscientists had underestimated the human capacity for neuroplasticity—how our brains continue to grow and develop throughout life. The good news is that you can do more than keep your brain from withering; you can make new connections among neurons and help to grow your brain.
Some of the earliest work on neuroplasticity was done with London taxi dr
ivers. I drove a taxicab in Manhattan while taking my premed courses at Columbia, so I was familiar with the rigors of the job and the creative approaches drivers employ to navigate complex cities. But London is much more complicated than New York, and the training to become a taxi driver is much more rigorous. Potential drivers need to learn the 320 “best routes” connecting thousands of “places of note” along the sixty thousand roads within a six-mile radius of central London—almost none of which go in a straight line and many of which are one-way and change names several times. The exams to become a taxi driver in London (known as Appearances) are notoriously difficult, and people typically spend three to four years acquiring “the Knowledge,” a deep familiarity with the particulars of the roads and places of note and how the routes that connect them must be combined and altered, depending on traffic conditions, to get to each destination efficiently.
Eleanor Maguire and Katherine Woollett, neuropsychologists at University College London, were curious. They wanted to see if changes could be noted in the brains of the taxi drivers, particularly in the posterior hippocampus—the area of the brain concerned with spatial memory. They scanned the brains of seventeen taxi drivers and eighteen bus drivers. They found that the posterior hippocampus was larger in taxi drivers, who need to constantly find new routes, compared with bus drivers, who don’t.1 The more the taxi drivers drove, the larger the posterior hippocampus. Then Maguire and Woollett studied seventy-nine taxi trainees and thirty-nine controls. Each driver had psychological testing and MRI scans at the start and end of their training. In those who passed the exam, the posterior hippocampus had grown. It hadn’t in the controls or in those who failed.2 Of note, those who did well spent twice as much time studying as those who didn’t.
The ability to assimilate vast quantities of knowledge and construct mental maps would sound familiar to any medical student. Medical students learn thousands of new words during their first two years of medical school, and each word—and the concept that it represents—is linked to other words in complex ways. Just as taxi drivers create mental maps of cities, medical students create mental maps of physiological and pathological pathways that manifest as health and disease. With repeated firing, these neural connections become better “lubricated,” so that mental tasks (such as memory and association) that previously took significant effort eventually become automatic. In time, the words are linked to real patients and thereby acquire personal meaning and emotional valence. The brain grows new connections—it rewires and reshapes itself. While behavioral scientist Donald Hebb proposed, as early as 1949, that “neurons that fire together wire together,”3 until recently you couldn’t actually see the rewiring in action. Now with sophisticated neuroimaging, it is possible to see how, with increasing practice, parts of the brain actually grow. The brain grows not only when you practice memory tasks and motor skills, but also when you practice “meta-skills”—skills of being attentive, curious, open-minded, and present. Admittedly, while the psychological and physical benefits of developing attentiveness and other aspects of mindfulness are clear, our knowledge of the actual changes in brain structure, chemistry, and functioning is still rudimentary.
WHAT MAKES A GREAT DOCTOR?
By the time they are a few years out from completing training, master clinicians have shaped their brains in particular ways to enhance specific abilities depending on what their work requires—knowledge, good judgment, emotional responsiveness, compassion, and technical skill. But how do master clinicians get that way? How can we help more clinicians get there?
The answers come from reexamining what we mean by expertise. In psychology, education, and health care, researchers have struggled with the question of expertise. For a long time researchers thought that natural talent accounted for a lot of it; you had a particular aptitude for singing or science, or soccer.
Psychologist Karl Anders Ericsson took another view—that expertise is largely a product of experience. Ericsson observed chess masters, musicians, and athletes and found that true masters don’t get that way just because they have natural talent; they engage in what he calls “deliberate practice.”4 Remember that the taxi drivers who passed the test had studied twice as much as those who didn’t. In Ericsson’s estimation, it takes about ten thousand hours of practice, or ten years, to have expertise in complex skills, whether the skills are chess playing or brain surgery (or taxi driving). However, it has to be high-quality practice, with supervision and feedback.
Ericsson also explored how doctors become experts, noting that expertise is different in medicine than in other pursuits. Chess players, musicians, and athletes typically start acquiring their skills as children, whereas doctors typically begin to acquire their skills when they’re in their twenties. Musicians, chess players, and athletes learn how emotions and attitudes affect performance—there’s the “inner game” and the “outer game.” There is much less talk of emotions in medical training. In chess, music, and sports, it’s usually clear that when things go wrong it’s due to someone having made an error. In medicine it’s not so clear. A patient’s outcome is not completely attributable to a doctor’s skill; so much depends on the particulars of each patient that are out of a physician’s control. Most important, for musicians, training is much more intimate and involves direct observation, critique, and feedback. When I was studying music, I’d be one-on-one with my piano teacher for an hour every week. Over time I’d anticipate and internalize what my teacher might say, and gradually I was able to critique myself. While surgeons benefit from direct supervision in the operating room, in most branches of medicine it is very different. When I was a medical student and a resident, I’d tell my supervising physicians what I had seen and accomplished, but only rarely did they actually observe me with a patient. My mentor George Engel suggested that we imagine what would happen if piano lessons were that way—you’d just report to your teacher what you had done well and where you perceived there were problems.5 You certainly wouldn’t get to Carnegie Hall that way.
Brothers Stuart and Hubert Dreyfus at the University of California, Berkeley, also observed professionals in a variety of fields. They developed a model in which they described a hierarchy from novice, to competent, proficient, and expert, later adding a level for master.6 For the Dreyfus brothers, expertise involved making automatic what for novices would be deliberate and effortful. The Dreyfuses suggested that experts could then reserve their cognitive resources for more complex tasks. For example, the nurse who took my blood pressure before a recent visit to my doctor was talking to me throughout. An expert, she could easily divide her attention between the automatic task and the (hopefully more interesting) interpersonal interaction, whereas a nursing student would have had to devote her full attention to what she was hearing through the stethoscope. Because these tasks become so automatic, experts, according to the Dreyfus brothers, often have difficulty describing exactly what they do.
Expertise is not merely automatic, though it also includes the ability to alternate—effortlessly—between automatic and effortful cognitive processing.7 When a nurse in my dentist’s office took my blood pressure two days after I saw my doctor, she was chatting just like the previous nurse. Then, suddenly she stopped. She took my pressure again, this time paying closer attention (I was not looking forward to the dental procedure, and my body let us know it). She slowed down. She noted an unusually high blood pressure. She switched gears.
Not every nurse would. While the ten-thousand-hours formula might work for developing basic skills, only if the practice is mindful will people learn to switch from automatic to effortful, to slow down when they should. Mindless practice, in contrast, leads to being an “experienced non-expert,” repeating the same mistakes over and over, without the insight to know why. Conversely, “true experts” are mindful and adaptive; they recognize when something’s amiss before others do. They observe and respond to context, then switch gears, slowing down and improvising.8 It’s like jazz.9
VOLUN
TARILY BRINGING BACK A WANDERING ATTENTION
Cultivating and sustaining attention is the sine qua non of good care. Over 120 years ago, William James devoted one of the first chapters of his Principles of Psychology to attention. James described—remarkably accurately—how attention works, setting the stage for future research. But he didn’t know how to cultivate it. He said, “The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will. . . . An education which should improve this faculty would be the education par excellence. But it is easier to define this ideal than to give practical directions for bringing it about.”10
Attention training is now common practice. It takes remarkably little to augment your capacity to attend. Even after a week of meditating thirty minutes a day, executive attention improves—if you recall, executive attention helps to reduce and reconcile conflicts between competing demands on your attention (such as someone talking to you when you’re trying to add up a column of numbers).11 After eight weeks of practice you’d likely have better sustained focus (top-down attention) and you’d be less likely to be derailed by the unimportant. With longer practice, some studies suggest that you’d be able to manage your precious cognitive resources more effectively and switch among mental tasks more quickly. You would be better able to remember key information, even when asked to multitask in highly stressful environments.12 With practice, you’d be more likely to notice and name your emotions, allowing you to respond more intelligently to strong feelings; you’d feel less frustrated when under high cognitive load; and you’d ruminate less about the past and worry less about the future. You’d become more present and more mentally fit.
Attending Page 19
