Attending

by Ronald Epstein

  Imagine that your doctor feels a sense of meaning in her work. Her work is difficult, stressful, and demanding, but your doctor has the self-awareness, mindfulness, and resilience to stay on top of things. Her meaningful relationships with patients sustain her through the workweek. She has enough control over scheduling and the organization of the office that she feels that she can do a good job. When dealing with the most difficult moments—when losing a patient, when witnessing needless suffering, when considering what might have contributed to a serious error, when making difficult ethical choices—she feels resilient and supported.

  This utopian vision of health care is shared by some of those who have the greatest influence in health care today. Don Berwick, M.D., formerly head of Medicare and Medicaid during the Obama administration, coined the “triple aim” of health care—better health care experiences for patients, better health outcomes for the population, and lower cost. Since then, family physicians Tom Bodenheimer and Christine Sinsky have added a fourth aim: improving the work lives of clinicians and staff who provide care. These aims have been embraced, at least in name, by an increasing number of health care organizations nationally.1

  I am a physician and not an organizational consultant, a CEO, or a manager. I take care of patients, one at a time. It took me a long time to realize that health care organizations have as much influence on my patients’ health as I do. Now, with current changes in health care, that reality has become apparent to anyone who has contact with the health care system. But health care organizations aren’t all the same. Only some truly embrace a vision of health care in which patients receive care that is effective, efficient, and affordable while sustaining the viability of the health care workforce and make real efforts to achieve those aims.2 Too often, though, health care institutions think only about productivity and throughput and don’t take into account what helps clinicians and staff to be at their best.

  Just like people, organizations themselves can be described as attentive, curious, responsive, and present—or not. They have the equivalent of top-down attention based on the goals of the organization as well as bottom-up attention, triggered by unexpected opportunities and challenges. And just like individuals, organizations pay selective attention to some things and ignore others, base decisions on incomplete knowledge, aren’t completely rational in their decision making, and muddle through when decisions are complex. Organizations have habits of mind, the collective habits that constitute an organization’s culture. Organizations can be described as mindful or less than mindful. In the transformation that I envision, health care organizations would promote mindfulness of individuals, health care teams, and of the organizational culture itself—down to how meetings are conducted, how information is communicated, and what values and behaviors are highlighted. They would create the conditions within which mindfulness could grow. The challenge is how to make this all happen.

  COLLECTIVE MIND

  The idea of mindfulness in organizations is not new. Karl Weick, at the University of Michigan’s Ross School of Business, first described the qualities of so-called high-reliability organizations in the 1990s. He visited aircraft carriers, nuclear power plants, airplane cockpits, and other settings in which a small error spells catastrophe. In the beginning of one of his articles, he asks the reader to imagine life on the flight deck of an aircraft carrier.3 Planes take off and land on a slippery flight deck at half the intervals that would be allowed at a civilian airport. This is all happening on a ship that is rocking from side to side with its radar turned off to avoid detection—and the whole operation is run by a group of twenty-year-olds. One glitch and the pilot, the airplane, and the ship go up in flames. Yet, errors are rare. It does not take much imagination to see the parallels between flight decks and busy urban trauma centers and operating rooms. However, in medicine we do far worse, with over one hundred thousand deaths per year due to medical error, and not nearly enough improvement in the fifteen years since the publication of a highly publicized report, To Err Is Human, by the Institute of Medicine.4

  Over the next twenty-five years, Weick and his colleagues identified features of what he called “high-reliability organizations” and was curious about how these organizations do their work—what they do, how they think and solve problems, and how they create organizational culture. Mindfulness was the missing link. Along with his colleague Kathleen Sutcliffe, Weick examined how organizations—as if the organizations were organisms—stand to gain by becoming more attentive, responsive, and reliable, and by learning to balance routine with innovation. They showed how freeing the mind from the concepts that constrain our thinking, the importance of beginner’s mind, and the concept of emptiness were as fundamental to well-functioning organizations as they were for well-functioning individuals.5 Weick advanced five basic principles of what he called “collective mind,” “organizational mindfulness,” and “organizational attention.”6

  First, Weick asserts, you need to be preoccupied with failure. There are just too many ways that things can go wrong, each unique and often unpredictable. That’s why it’s important, in Weick and Sutcliffe’s words, to learn how to manage the unexpected—being prepared to be unprepared. This preparation should be part of institutional culture.7

  Weick and Sutcliffe’s second principle is to be reluctant to simplify. Just as individuals get derailed by using mental shortcuts, teams and organizations do too. When Mr. Laszlo, the patient I discussed in chapter 2, came in with a painful shoulder, three out of three clinicians sought a simple answer that was logical—and wrong. When my friend Gary went to the emergency room with urinary obstruction (chapter 4), the nurses and doctors caring for him made the same kind of mistake. They picked the most convenient explanation. They didn’t question it; their minds were too crowded and there was too much pressure to move on to the next patient. In the ER, there might even have been an underlying organizational culture, one in which having a quick answer—any answer—was rewarded and deeper cognitive processing was not. Those caring for Gary lacked attention and presence, not just individually, but collectively.

  Weick and Sutcliffe’s third principle is sensitivity to operations—management speak for what in medicine is called situation awareness. Here, health care institutions have made progress. In most institutions, clinical teams who work in hospitals—such as in the OR, the ICU, and the labor and delivery floor—undergo team training to help members speak up when they observe a problem. Even when people are not part of a team, they’re encouraged to speak up. The person who mops the floors might have better insight into why infections are rampant in an ICU than the director of infection control. Weick suggests that safety be given higher priority than efficiency—not just in word, but in deed. This involves a mindful redirection of attention toward things that might otherwise be ignored.

  Commitment to resilience, Weick and Sutcliffe’s fourth principle, is more than bouncing back. Like individual resilience, organizational resilience depends on learning and growing from crises, and working outside people’s comfort zones. You need teams of adaptive experts, people who can learn from the past but also know when to let go of it.

  Their last recommendation is the one that surprised me the most, in a pleasant way. Weick and Sutcliffe call for greater anarchy in organizations. In healthy organizations, they claim, decisions should be made by the most appropriate member of the hierarchy and shouldn’t have to be delayed until they come to the attention of the leadership. Weick and Sutcliffe are not talking about total anarchy here, but about loosening the boundaries just a bit so that more decisions are made by the people closest to the problem. These make routines and structures in the organization a bit more fluid.8 In my office, medical assistants take patients’ pulse, temperature, and blood pressure and ask them what’s bothering them when they arrive. The most helpful medical assistants are the ones who note that something is different—the patient’s blood pressure is lower or higher than it should be—and interrupt me to bring it
to my attention immediately rather than just recording it in the chart. At the other extreme was a medical assistant who recorded the patient’s chief concern as “chest pain,” entered it into the medical record correctly, then left the patient to wait in a room for a half hour until his physician saw him. The patient was having a heart attack. The medical assistant’s failure was not merely an individual’s lapse or irresponsibility; it reflected poor training and a culture that didn’t reinforce mindfulness.9

  QUALITY AND SAFETY

  Promoting quality in health care should build on a foundation of individual mindfulness and at the same time develop organizational mindfulness. Institutions should be structured so that collective vigilance is the norm, so that it matters less if any one individual suffers a lapse in attention. For example, one difficult problem in health care has been preventing falls among the elderly. Falls are common, and if the patient is injured or in pain, she ends up immobilized. Even after a few days in bed, elderly patients lose strength and require additional rehabilitation, and even still they might not ever get back on their feet. Immobilization leads to infections and blood clots, and mortality can be as high as 50 percent in the ensuing year. Preventing falls takes collective vigilance. Nurses need to be alert to when patients are unstable or are trying to get out of bed when they shouldn’t. When a bed alarm goes off, the response has to be quick and coordinated, as it often takes more than one person to get the patient to safety. One factor in reducing falls, according to Timothy Vogus at Vanderbilt University, is collective mindfulness. He studied ninety-five nursing units to see if scores on a mindfulness survey, assessing the five components defined by Weick and Sutcliffe, would predict on which nursing units patients fell. Those units whose members collectively scored higher had fewer falls—and, also of note, fewer medication errors.10

  Health care organizations should consider the human capacity for attention when designing clinical work spaces, ones free of frequent interruptions and distractions. When I’m working in the emergency room, where the decibel level is high and there’s a potential distraction every few seconds, I mentally block out ambient sounds so that I can pay attention to my patient. It’s exhausting. When it comes time to write my notes on the computer, I’m faced with a choice—wall myself off with varying degrees of success or go to a quieter space on another unit, a five-minute walk and five flights of stairs away. There has to be a better way. Mindful work-space design can make paying attention possible.

  HUMAN CONVERSATIONS

  Health care institutions can create the conditions for caring and compassion. Health care consultant and internist Tony Suchman says that part of the answer is in moving from a command-and-control leadership style to one that is more relationship centered.11 Suchman describes relationship-centered leadership as a style that honors the unique individual contributions of each member while helping them contribute to the overall mission. Mindful leaders enshrine the human side of medicine in hospital culture, provide space for meaningful conversations among members of the organization, and discover employees’ untapped strengths. Suchman takes a radical view of organizations—that they are no more than a collection of conversations among people, setting the stage for appreciative inquiry and other methods to enhance motivation and self-awareness, promote effective teamwork, and help individuals sustain a sense of vision, purpose, and meaning.12

  Leaders should promote inquiry, awareness, and attention to things that matter and that the organization values. Over the past two years, I spent several days at a large Catholic health care system and was the keynote speaker at a conference of the Catholic Health Association. I was struck with several cultural differences between Catholic health systems and the secular world of university hospitals. First, they had an explicit commitment to caring and compassion. In chapter 7, I described how I checked out hospital mission statements looking for mention of suffering; at the same time I also looked for the word compassion. Nearly all of the Catholic health systems mentioned compassion explicitly, whereas almost none of the secular hospital systems did. Perhaps where the word compassion is spoken more often, it is enacted more often. But these are interesting times. Catholic hospitals in the United States have traditionally cared for everyone, even those with no means to pay. Historically they were run by nuns. Now they are typically run by lay leadership and are experiencing growing pains as they compete for market share and merge with other hospitals. However, I was intrigued by a role that they still had in their administrative structure and that I had not seen in other hospitals—directors of “formation.” These people orient health care workers to consider such questions as “Where do I find meaning each day?” “What grounds this work?” “To what are we called together?” and “How must we respond?” I find these questions important, regardless of one’s spiritual orientation. They address the technical as well as the existential, ethical, and social aspects of care. These hospitals’ commitment to formation and mission is right on the mark. I found it particularly refreshing after having visited with institutions whose investment in compassion is little more than a sticker on a white lab coat that says I CARE.13

  Ken Schwartz was a successful Boston attorney who represented health care institutions. He was diagnosed with metastatic cancer at age forty and died ten months later, but not before recognizing what was most important—and sometimes most lacking—in the health care he received. He published his account in the Boston Globe and pointed to the small acts of kindness that made “the unbearable bearable.” His final wish was to create an organization that would nurture compassion, caregiver-patient relationships, and humane care. Founded in 1995, shortly before Ken Schwartz’s death, the Schwartz Center for Compassionate Healthcare14 has a signature program called Schwartz Rounds, which is currently in place at over five hundred health care institutions in North America and the UK. Schwartz Rounds focus on a patient with complex medical issues that require an interdisciplinary approach. Each session assembles a patient’s care team, which may include physicians, nurses, therapists, chaplains, and others who have meaningful contact with the patient and his family. Panelists talk openly about the difficulties they’ve encountered caring for the patient. Sometimes the patient or a family member is present to add to the discussion.

  In a recent Schwartz Rounds at my hospital, a mother reflected on her experiences during a recent hospitalization for her severely disabled son, one of many hospitalizations for seizures, pneumonia, and weight loss. The care team, including a pediatric geneticist, the ICU physician, a nurse, a social worker, and a chaplain, described the child’s predicament, how they each were affected by his suffering, knowing that little could be done to reverse his decline. Importantly, the 150 attendees, from a wide variety of disciplines and specialties, as well as the patient’s mother, discussed how the health care system could best support the family. Discussions like this, in a well-attended forum, rarely happened in hospitals until the Schwartz Center started supporting them. Now, in our institution and others, Schwartz Rounds occur monthly and are a source of community building for the medical and nursing staff. A few years ago, Beth Lown, an internist and medical director at the Schwartz Center, assessed the impact of Schwartz Rounds.15 Those who had attended reported deeper insight into the emotional lives of patients and caregivers. They communicated better—verbally and nonverbally—and felt more equipped to respond to patients’ needs with compassion. They were more energized about their work. They felt less stressed and isolated and more open to providing and accepting support. They became more mindful by learning to speak from the heart, just as the panelists had done.

  The Arnold P. Gold Foundation has a similar mission, and has pioneered the “white coat ceremony,” conducted at nearly all of the medical schools in North America, to mark the transition from student to healer. By asking students to develop and commit to a set of professional vows, the ceremony brings students’ awareness, at the beginning of their careers, squarely to the values, attitudes, and attribu
tes that they each bring to the profession—a guidepost for more mindful, humane care.

  A CORD OF THREE STRANDS

  It seems so sensible that quality of care, quality of caring, and clinician resilience would be synergistic. Even in these difficult times in health care, I see more and more health professionals tending to the soil in which their focused attention, curiosity, creativity, compassion, and resilience can grow. Yet, they are doing this in spite of their organizations, which they continue to find unsympathetic and unsupportive. Creating mindful organizations starts with respecting the clinicians who work there. Organizations should provide opportunities during the workday for clinicians to grow professionally and not make those offerings add-ons to an already overcrowded day. At some institutions, self-awareness and mindfulness constitute an essential part of the required curriculum for students and residents,16 and these institutions frame self-awareness as essential to good patient care. Each of us has a lot at stake. When I teach medical students, I do so knowing that they represent the future of medicine. I assume that each student will become the doctor that I might encounter in the emergency room if I have another kidney stone, in the oncology clinic if I have cancer, or in the hospital if I need surgery. In fact, this has happened; some of my students have been my doctors. And I am hopeful. While some medical school graduates consider medicine as nothing more than a job, when I informally polled several medical school classes recently, the majority had done some kind of contemplative practice and see value in it for themselves as professionals. They see medicine as deeply meaningful work.

  Attending—where you focus your precious attentional resources—is a choice, a moral choice. When I started thinking about mindful practice in medicine twenty years ago, I saw it as an individual commitment to be more attentive and curious, have a beginner’s mind, and be present. I described the skills necessary to move from being a mere expert to a master, with the associated insight, perspective, and creativity. Now I see the project as much larger. Like the African proverb about raising a child, mindful practice takes a village. Having a community of colleagues, peers, and others who share a vision of mindful practice makes it possible. In clinical care the beneficiaries are our patients, who themselves may bring attention and awareness to their own work, whether they are artists, schoolteachers, bus drivers, or lawyers. Mindfulness is an aspiration of an increasing number of individuals and large educational and corporate institutions that comprise our society. I believe that now it is possible, with the right resolve, to have health care infused with and guided by mindful practice. A cord of three strands—individual, collective, and institutional—is not quickly broken.